Read the information below.

Client reports pain at surgical incision site as 5 on a scale of 0 to 10.

Client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.

Client transferring out of bed to chair independently.

Extremities cool and dry with 2+ peripheral pulses.

Client reports abdominal cramping and small, hard, painful bowel movement after lunch.

Ambulating independently in hallway.

Reports pain as 8 on a scale of 0 to 10, Urinary catheter intact with 100 mL/hr of pink urine.

Encourage prolonged dangling before ambulation.

Irrigate indwelling catheter with 500 mL of fluid.

Administer an enema.

Assist the client with a sitz bath.

Encourage oral fluid intake.

Answer and Explanation

The Correct Answer is E

Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.

The other options are not appropriate based on the information provided:

"Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
"Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
"Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
"Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.

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Correct Answer is B

Explanation

Explanation

B.Hypertension

Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.

Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.

The other options are not specifically associated with the adverse effects of tranylcypromine:

Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.

Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.

Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.

A. Case manager B. Nutritionist C. Primary care provider D. Pediatric nurse practitioner

Correct Answer is A

Explanation

A case manager is a member of the interprofessional team who specializes in coordinating and facilitating access to healthcare services and resources for individuals and families. They can assist the client in identifying and accessing financial assistance programs or resources that can help with the cost of baby formula.

Case managers have knowledge of community resources and can provide guidance and support in navigating the system to meet the client's needs. While a nutritionist may provide guidance on infant nutrition, they may not have direct access to financial assistance programs or resources. The primary care provider and pediatric nurse practitioner may be involved in the client's care but may not have the specific expertise in addressing financial concerns.

Therefore, referring the client to a case manager is the most appropriate action in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

Correct Answer is A

Explanation

A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?

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