In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Blood pressure.

Urinary output.

Respiratory rate.

Temperature.

Answer and Explanation

The Correct Answer is A

Rationale:
A.   MAO inhibitors such as phenelzine can cause significant fluctuations in blood pressure, including hypertensive crisis when combined with certain foods or medications. Therefore, monitoring blood pressure is crucial to detect and prevent hypertensive emergencies.
B.   While monitoring urinary output is important for overall assessment, it is not specifically associated with the use of MAO inhibitors like phenelzine.
C.   Respiratory rate is not typically affected by MAO inhibitors like phenelzine and may not be the most relevant assessment finding in this scenario.
D.   Temperature monitoring is important for general assessment but is not specifically associated with the use of MAO inhibitors like phenelzine.

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Correct Answer is A

Explanation

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

A. Episodic intervals of pruritus. B. Erythema of the localized lesions. C. Ecchymotic blood accumulations. D. Evidence of patches of lost hair.

Correct Answer is C

Explanation

A. Episodic intervals of pruritus (itching) may suggest a dermatological condition or irritation of the scalp, but they do not directly indicate that the hair loss is not disease-related.
B. Erythema (redness) of the localized lesions may suggest inflammation or irritation but does not necessarily indicate that the hair loss is not disease-related.

C. Ecchymotic blood accumulations (bruising) suggest trauma or repeated pulling at the hair, which is not typically associated with disease-related causes. This finding can indicate a behavioral issue, such as trichotillomania (a compulsive hair-pulling disorder), where physical damage to the scalp can result in bruising and bald patches. The presence of ecchymosis supports a mechanical, non-disease-related cause of hair loss.

D. Evidence of patches of lost hair alone does not confirm whether the hair loss is disease-related or non-disease-related. Patches of hair loss can occur with both behavioral conditions (e.g., trichotillomania) and diseases (e.g., alopecia areata, fungal infections).

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In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Correct Answer is A

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

Correct Answer is C

Explanation

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