A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

When educating the client about their medication, the nurse should teach the client that there is a risk for hypertensive crisis due to ingestion of tyramine.

Choice A: Hypertensive Crisis

Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.

Choice B: Tardive Dyskinesia

Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.

Choice C: Rhabdomyolysis

Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.

Choice D: Infection

Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.

Choice E: Nervous System Instability

Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.

Choice A: Hypertensive Crisis

Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.

Choice B: Tardive Dyskinesia

Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.

Choice C: Rhabdomyolysis

Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.

Choice D: Infection

Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.

Choice E: Nervous System Instability

Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.

Choice A:
GHB (gamma-hydroxybutyric acid) is known to cause nausea and vomiting, especially at higher doses. These symptoms are common side effects of GHB ingestion and can be distressing for the patient.
Choice B:
Confusion is a significant complication associated with GHB use. GHB acts as a central nervous system depressant, leading to altered mental status and confusion. This can impair the patient’s ability to communicate effectively and understand their surroundings.
Choice C:
Tachycardia, or an abnormally fast heart rate, is not typically associated with GHB use. GHB tends to cause bradycardia (slowed heart rate) rather than tachycardia. Therefore, this option is not a correct answer.
Choice D:
Hypothermia, or abnormally low body temperature, is not a common complication of GHB use. GHB does not typically affect body temperature regulation in a way that would lead to hypothermia. Thus, this option is not a correct answer.
Choice E:
Amnesia is a well-documented effect of GHB, often referred to as the “date rape drug” due to its ability to cause memory loss1. This can result in the patient having no recollection of events that occurred while under the influence of the drug.
Choice F:
Respiratory depression is a severe and potentially life-threatening complication of GHB use. GHB can depress the central nervous system to the point where breathing becomes slow and shallow, which can lead to respiratory failure5. This is a critical concern in managing patients who have ingested GHB.