The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

The correct answer is c. Pepperoni pizza and red wine.

Choice A Reason:

Apple pie and coffee are generally safe to consume while taking MAOIs. These foods do not contain high levels of tyramine, which is the substance that can cause dangerous interactions with MAOIs. Tyramine is found in aged, fermented, or cured foods, and neither apple pie nor coffee falls into these categories.

Choice B Reason:

A bagel with cream cheese and tea is also considered safe for individuals taking MAOIs. Cream cheese is a fresh cheese and does not contain high levels of tyramine. Tea, while containing caffeine, does not pose a significant risk of tyramine interaction.

Choice C Reason:

Pepperoni pizza and red wine are high in tyramine and should be avoided by individuals taking MAOIs. Pepperoni is a cured meat, and red wine is a fermented beverage, both of which can lead to a hypertensive crisis when consumed with MAOIs. This combination can cause a dangerous spike in blood pressure, making it the correct answer to the question.

Choice D Reason:

Potato chips and diet cola do not contain high levels of tyramine and are generally safe to consume while taking MAOIs. Potato chips are not aged or fermented, and diet cola, although containing caffeine, does not pose a significant risk of tyramine interaction.

a. Assist the client to develop more effective coping mechanisms

c. Identify community resources for the client to use in a crisis

d. Educate the family about providing a safe and structured environment for the client

Explanation of Choices

Choice A Reason: Assist the Client to Develop More Effective Coping Mechanisms

Developing effective coping mechanisms is crucial for clients with a history of suicide attempts. Coping strategies help individuals manage stress, anxiety, and other emotional challenges that may trigger suicidal thoughts. Effective coping mechanisms can include mindfulness practices, cognitive-behavioral techniques, and stress management skills. By assisting the client in developing these skills, nurses can help reduce the risk of future suicide attempts and improve the client’s overall mental health.

Choice B Reason: Have a One-to-One Sitter for Outpatient Use

While having a one-to-one sitter can be beneficial in an inpatient setting to provide constant supervision and ensure safety, it is not typically feasible or necessary for outpatient care. Outpatient settings focus more on empowering the client with skills and resources to manage their condition independently. Continuous supervision in an outpatient setting may not be practical and could hinder the client’s sense of autonomy and self-efficacy.

Choice C Reason: Identify Community Resources for the Client to Use in a Crisis

Identifying community resources is a vital intervention for clients with a history of suicide attempts. Community resources can include crisis hotlines, support groups, mental health clinics, and emergency services. Providing the client with information about these resources ensures they have access to immediate help during a crisis. This support network can be crucial in preventing future suicide attempts and providing ongoing emotional and practical support.

Choice D Reason: Educate the Family About Providing a Safe and Structured Environment for the Client

Family education is essential in the care of clients with a history of suicide attempts. Educating the family about creating a safe and structured environment can help reduce triggers and stressors that may lead to suicidal thoughts. This education can include removing potential means of self-harm, establishing routines, and promoting open communication. A supportive family environment can significantly enhance the client’s recovery and reduce the risk of future suicide attempts.

Choice E Reason: Isolate the Client from All Stressful Situations That May Precipitate a Suicide Attempt

Isolating the client from all stressful situations is not a practical or effective intervention. While it is important to minimize exposure to significant stressors, complete isolation is neither feasible nor beneficial. Instead, the focus should be on helping the client develop resilience and coping strategies to manage stress. Learning to navigate and cope with stress is a critical part of recovery and long-term mental health management.