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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: While assessing for symptoms of cocaine withdrawal is important, educating the client about the purpose and side effects of the medication is the priority when initiating new pharmacological treatment.

Choice B rationale: Educating the client about the purpose and side effects of the medication promotes understanding and adherence to the treatment plan, addressing the client's cravings.

Choice C rationale: Encouraging the client to take the medication as prescribed is important, but educating them about the medication takes precedence.

Choice D rationale: Determining when the client last used cocaine is relevant but does not directly address the education needed for medication management.

A. Self-control. B. Self-actualization. C. Self-esteem. D. Self-absorption.

Correct Answer is C

Explanation

Choice A rationale: Self-control is not the primary issue identified in this scenario. The client's self-blame may be related to other factors.

Choice B rationale: Self-actualization is not the primary issue in this scenario. The client is dealing with feelings of self-blame and potential guilt.

Choice C rationale: Self-esteem is the most relevant issue in this scenario. The client expresses feelings of self-blame, indicating a potential impact on self-esteem. Addressing self-esteem is crucial for the client's emotional well-being.

Choice D rationale: Self-absorption is not the primary issue in this scenario. The client's focus on self-blame and guilt is related to self-esteem concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to Include in this phase of the nurse-client relationship?

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?