A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods.
The nurse should monitor the client for which of the following findings as an adverse effect of this medication?
Hyperglycemia
Hypertension
Hematuria,
Tinnitus
The Correct Answer is B
Explanation
B.Hypertension
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.
Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.
The other options are not specifically associated with the adverse effects of tranylcypromine:
Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.
Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.
Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A.Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
Correct Answer is A
Explanation
A.Giving change-of-shift report to a nurse outside the client's room ensures that client information is shared in a private, secure setting, reducing the risk of unauthorized individuals overhearing sensitive information.
B.While sharing information with staff involved in the client's care is generally acceptable, discussing detailed prognosis with assistive personnel (who may not have a need-to-know role) is inappropriate. Confidential information should only be shared with those directly involved in the patient's care as part of the care team.
C.This is a clear violation of confidentiality, as it exposes the client's private health information to anyone who may access the room.
D.This is a breach of confidentiality, as the information could be accessed by unauthorized individuals. The appropriate way to dispose of confidential information is to shred it or return it to the medical record.
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