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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale: "Do you think someone is trying to harm you?" is a leading question and may contribute to the client's paranoid thoughts. It is important to explore the client's concerns without making assumptions.

Choice B rationale: "What makes you think people are stalking you?" is an open-ended question that invites the client to share more about her experiences and thought processes. It allows for a deeper exploration of the client's perceptions.

Choice C rationale: "It sounds like this experience is frightening for you" is a closed statement and may not encourage the client to elaborate on her thoughts. Open-ended questions are more effective in this situation.

Choice D rationale: "I know you are frightened, but no one is stalking you" is a dismissive statement that may invalidate the client's feelings. It is imp

A. Refer the client to the cardiology clinic. B. Obtain the client's blood pressure. C. Determine if alprazolam was taken recently. D. Assess the client for substance abuse.

Correct Answer is B

Explanation

Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.

Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.

Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.

Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

Correct Answer is B

Explanation

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?

Correct Answer is B

Explanation

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

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

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?