A client with a history of anxiety and depression presents to the emergency department with a headache, nausea, and vomiting. The client's vital signs are temperature 100.9°F (38.3°C), heart rate 115 beats/minute, respirations 21 breaths/minute, and blood pressure 216/108 mm Hg. When reviewing the client's medications, which information is of most concern to the nurse?
Hydrochlorothiazide 12.5 mg PO daily.
Phenelzine 60 mg PO daily.
Losartan 50 mg PO daily.
Aspirin 81 milligrams PO daily.
The Correct Answer is B
Choice A rationale: Hydrochlorothiazide is a diuretic and may contribute to electrolyte imbalances, but it is not the most concerning medication in this situation. Choice B rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and the combination of an MAOI with certain foods or medications containing tyramine can lead
to a hypertensive crisis. The client's elevated blood pressure is of concern, and the nurse should notify the healthcare provider.
Choice C rationale: Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. While it may contribute to blood pressure control, it is not the most concerning medication in this scenario.
Choice D rationale: Aspirin, at a dose of 81 milligrams, is often used for cardiovascular prophylaxis and is not the most concerning medication in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Altruism involves addressing one's own needs through meeting the needs of others, and caring for the husband's aging parents is an example of this coping mechanism.
Choice B rationale: Regression involves reverting to an earlier stage of development, which is not evident in the scenario.
Choice C rationale: Compartmentalization is the defense mechanism of separating conflicting thoughts or feelings, which is not clearly identified in the scenario. Choice D rationale: Egocentrism involves seeing the world from only one's own perspective, which is not the primary issue in the scenario.
Correct Answer is C
Explanation
Choice A rationale: "If your partner is abusing you, I need to ask these questions" may be too direct and could potentially make the client feel pressured or uncomfortable. The nurse should emphasize the routine nature of the screening.
Choice B rationale: "The healthcare provider needs to know if you are experiencing any domestic abuse" is correct but may sound directive. Emphasizing the routine nature of the screening helps to normalize the process.
Choice C rationale: "All clients are screened for domestic abuse because it is common in our society" is the best choice. It normalizes the screening process, reducing stigma and encouraging disclosure.
Choice D rationale: "State law mandates that I ask if you are a victim of domestic violence" may make the client feel compelled to answer due to legal reasons, potentially affecting the validity of the response. Emphasizing routine screening is a more patient centered approach.
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