A nurse in an outpatient mental health facility is preparing to administer phenelzine to a client who has been taking this medication for several years. The client reports eating a grilled cheese sandwich and a banana for lunch and is feeling dizzy. Which of the following vital signs should the nurse assess first?
Blood pressure
Respiration
Pulse
Temperature
The Correct Answer is A
Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.
Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.
Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.
Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.
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Correct Answer is D
Explanation
Choice A reason: While discussing the client's diagnosis with their family could be part of the care process, it does not address the client's immediate concern about the quality of care they are receiving. This response does not validate the client's feelings or provide an opportunity for them to elaborate on their concerns.
Choice B reason: Telling the client that their feelings are part of anticipatory grieving may be true, but it can come across as dismissive and does not offer support for the specific issue the client has raised about the quality of care.
Choice C reason: Assuring the client that the nurses are trying to provide good care does not acknowledge the client's perception of inadequate care. It's important to validate the client's feelings and understand their perspective before offering reassurances.
Choice D reason: Asking the client to elaborate on their concerns shows empathy and a willingness to listen. It allows the nurse to gather more information about the client's experience and identify specific areas that may need improvement in the care provided.
Correct Answer is A
Explanation
Choice A reason: Listing the negative effects of alcohol use can help the client gain insight into the consequences of their actions and reinforce their motivation to remain sober. Reflecting on personal losses and health issues due to alcohol can be a powerful deterrent against relapse.
Choice B reason: While attending support group meetings can be beneficial, saying "as needed" may not provide the structured support necessary for preventing relapse. Regular attendance at support groups like Alcoholics Anonymous (AA) is often recommended for sustained recovery.
Choice C reason: Lorazepam is not typically prescribed to prevent relapse in alcohol use disorder due to its potential for abuse and dependence. Instead, medications like naltrexone or acamprosate may be considered to help maintain abstinence.
Choice D reason: Revisiting familiar places may trigger cravings and is generally not advised. Instead, clients are encouraged to avoid places associated with their past alcohol use to reduce the risk of relapse.
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