A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

A.While consistency in staff assignment can be beneficial in many situations, clients with borderline personality disorder often exhibit splitting behavior, where they may see people as all good or all bad. It's more important to provide consistent boundaries rather than focusing solely on staff consistency, as this might inadvertently reinforce splitting behavior.

B.While being empathetic is important in nursing care, being overly sympathetic might reinforce dependency or manipulative behaviors commonly seen in borderline personality disorder. It's crucial to maintain a professional, empathetic, yet firm approach that includes setting and maintaining boundaries.

C.Clients with borderline personality disorder often struggle with boundary issues and can exhibit behaviors such as manipulation, splitting, and impulsivity. Providing consistent boundaries helps create a sense of stability and predictability, which is therapeutic and helps the client learn appropriate interpersonal skills.

D.Encouraging the use of countertransference is not appropriate and can lead to an unprofessional and emotionally charged nurse-client relationship, which can be harmful to the therapeutic process. Instead, nurses should be aware of and manage their own feelings to provide effective and impartial care.

The correct answer is Choice b, Blood pressure.

Rationale for Choice a, Bowel sounds:

• Bowel sounds are not directly relevant to the potential interaction between phenelzine and pepperoni pizza.
• While assessing bowel sounds is a part of a comprehensive nursing assessment,it would not be the top priority in this specific scenario.
• Phenelzine does not typically cause gastrointestinal disturbances that would warrant immediate assessment of bowel sounds.

Rationale for Choice c, Oxygen saturation:

• Oxygen saturation is not directly affected by the interaction between phenelzine and pepperoni pizza.
• Assessing oxygen saturation would be more pertinent in situations involving respiratory distress or hypoxia.
• There is no evidence to suggest that this interaction would cause respiratory depression or compromise oxygen saturation levels.

Rationale for Choice d, Pupil response:

• Pupil response is not a reliable indicator of the potential complications associated with phenelzine and tyramine-rich foods.
• It's primarily assessed for neurological conditions or drug intoxication affecting the central nervous system.
• The interaction between phenelzine and tyramine primarily affects the cardiovascular system,not the neurological system.

Rationale for Choice b, Blood pressure:

• Blood pressure is the most critical assessment in this scenario due to the potential for a hypertensive crisis.
• Phenelzine is a monoamine oxidase inhibitor (MAOI),which blocks the breakdown of tyramine,a substance found in certain foods like pepperoni,aged cheeses,and fermented products.
• When tyramine levels increase,it can trigger a sudden and severe rise in blood pressure,known as a hypertensive crisis.
• Symptoms of a hypertensive crisis can include:
  • Severe headache
  • Neck stiffness
  • Chest pain
  • Nausea
  • Vomiting
  • Blurred vision
  • Sweating
  • Photophobia (sensitivity to light)
  • Palpitations
  • Anxiety
  • Confusion
  • Seizures
  • Stroke
  • Potentially death
• Prompt assessment of blood pressure is crucial for early detection and intervention to prevent these life-threatening complications.