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?

Urinary output.

Blood pressure.

Respiratory rate.

Temperature

Answer and Explanation

The Correct Answer is B

A.   Urinary output might be important in some contexts but is not the priority related to the use of MAO inhibitors.
B.   MAO inhibitors like phenelzine can affect blood pressure significantly; monitoring BP is crucial due to the risk of hypertensive crisis when certain foods or medications are taken.
C.   Respiratory rate might be a consideration in some situations but is not directly affected by MAO inhibitors.
D.   Temperature is not typically a primary concern related to MAO inhibitor use; blood pressure monitoring is more crucial due to potential interactions.

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Correct Answer is B

Explanation

A. Role-playing might not be suitable for a hyperactive 4-year-old with potential autism, as their attention span and ability to engage in structured activities might be limited.
B. Adolescents often benefit from role-playing to navigate social situations and address feelings of rejection or lack of acceptance from peers.
C. Role-playing might not be as effective for an older adult in a long-term care facility who takes others' belongings, as this behavior may require different interventions.
D. While role-playing can be helpful for individuals with schizophrenia, their tendency to refuse medications might not necessarily be addressed through this method.

A. Provide for personal space. B. Stand in the doorway. C. Request backup from the staff D. Encourage the client to sit down.

Correct Answer is A

Explanation

A. Providing personal space allows the client to feel less threatened and gives them room to express their emotions without feeling cornered.
B. Standing in the doorway might block the client's exit and could escalate the situation.
C. Requesting backup might be necessary in some situations but should not be the initial response to the client's agitation.
D. Encouraging the client to sit down might not be well-received and could escalate the situation further.

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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 plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Correct Answer is B

Explanation

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Correct Answer is A

Explanation

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition?