A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?
Significant weight loss.
Psychomotor retardation.
Markedly neglected hygiene.
Poor problem-soling skills.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A, displacement.
Rationale for Choice A, displacement:
- Definition of displacement:Displacement is a defense mechanism in which a person redirects their emotions or impulses from the original target to a less threatening one.It's a way of coping with anxiety or frustration by channeling those feelings onto a safer object or person.
- Evidence in the scenario:The client is angry with his partner,but instead of expressing that anger directly to her,he redirects it towards the nurse.This suggests that he finds it safer to express his anger towards the nurse,who is less likely to retaliate or reject him,than towards his partner.
Rationale for other choices:
- Choice B, rationalization:Rationalization involves justifying one's actions or thoughts with excuses or explanations that make them seem more acceptable.There's no evidence in the scenario that the client is trying to justify his anger or provide excuses for it.
- Choice C, denial:Denial involves refusing to acknowledge or accept a painful reality.The client isn't denying his anger; he's openly expressing it.However,he's directing it towards the nurse instead of his partner.
- Choice D, compensation:Compensation involves trying to make up for a perceived weakness or inadequacy by emphasizing a different strength or ability.There's no indication in the scenario that the client is trying to compensate for anything.
Further considerations:
- It's important to note that defense mechanisms are often unconscious,meaning the person using them isn't aware of what they're doing.This can make them difficult to identify and address.
- In this case,the nurse could try to help the client become more aware of his anger and how he's expressing it.They could also encourage him to explore healthier ways of coping with his feelings,such as talking to his partner directly or seeking professional help.
Correct Answer is B
Explanation
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.
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