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 C

Explanation

A. "The snakes on the wall are going to eat me" indicates a hallucination, specifically a visual hallucination. Hallucinations involve perceiving something that is not present, such as seeing or hearing things that others do not. This statement does not confirm delusions.

B. Hearing voices instructing harm doesn't confirm delusions but auditory hallucinations.

C. "The nurse at night is trying to poison me with pills" reflects a delusion, specifically a persecutory delusion. Delusions are false, fixed beliefs that are not based in reality and are resistant to reasoning or contradictory evidence. This statement indicates a belief that someone is attempting harm, which is characteristic of delusional thinking.

D. Believing fire is burning the skin could suggest a hallucination involving sensations, not necessarily a delusion.

A. Thoughts of wanting to hurt himself. B. Frequent days with diarrhea. C. Weight gain of 75 pounds (34 kg). D. Altered liver function tests.

Correct Answer is C

Explanation

A. Thoughts of wanting to hurt himself might be associated with various mental health conditions or medications but aren't specifically linked to olanzapine.
B. Diarrhea is a less common side effect of olanzapine and is not among the more frequently reported side effects.
C. Weight gain is a well-known side effect of olanzapine, with substantial increases reported in some cases.
D. Altered liver function tests are less commonly associated with olanzapine use compared to weight gain.

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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 documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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