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

Answer and Explanation

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 A

Explanation

Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.

Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.

Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.

Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.

A. "List the negative effects of alcohol use in your life." B. "Attend support group meetings as needed." C. "You can get a prescription for lorazepam to prevent relapse." D. "Revisit familiar places for support."

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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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?

Correct Answer is A

Explanation

A nurse is providing teaching for a client who has an alcohol use disorder. Which of the following statements should the nurse make to help prevent relapse?

Correct Answer is A

Explanation

A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?

A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

Exhibits A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)