A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

A. Hypotensive shock: This is not the correct answer. MAO inhibitors are not associated with causing hypotensive shock. In fact, they can lead to an increase in blood pressure.

B. Hypertensive crisis: This is the correct answer. MAO inhibitors interact with certain foods and drugs, such as those containing tyramine, leading to an increased risk of a hypertensive crisis. Foods rich in tyramine, such as aged cheeses, certain wines, and some processed meats, can cause a sudden and dangerous increase in blood pressure when combined with MAO inhibitors.

C. Cardiac dysrhythmia: While all medications have potential side effects, MAO inhibitors are not typically associated with causing cardiac dysrhythmias.

D. Cardiogenic shock: MAO inhibitors are not known to cause cardiogenic shock. The primary concern with MAO inhibitors is the potential for a hypertensive crisis due to interactions with specific foods and drugs.

A. Implement the client's behavioral modification plan:

While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.

B. Document the size and location of the cuts:

Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.

C. Administer a tetanus antitoxin:

Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.

D. Inspect the cuts for debris:

This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.