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: Chlordiazepoxide is a benzodiazepine that is commonly used to treat the symptoms of acute alcohol withdrawal. It works by enhancing the effect of the neurotransmitter GABA, which has an overall calming effect on the nervous system. This helps to reduce the severity of withdrawal symptoms such as anxiety, agitation, and the risk of seizures.

Choice B reason: Buprenorphine is an opioid partial agonist-antagonist used primarily to treat opioid addiction and is not typically used for alcohol withdrawal. While it can help with some withdrawal symptoms, it does not address the full spectrum of alcohol withdrawal symptoms and is not the standard treatment for this condition.

Choice C reason: Bupropion is an antidepressant and smoking cessation aid. It affects neurotransmitters in the brain but is not indicated for the treatment of alcohol withdrawal. Therefore, it would not be the expected medication for managing acute alcohol withdrawal symptoms.

Choice D reason: Disulfiram is used as a deterrent agent in the management of chronic alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed, which helps to maintain abstinence but is not used for treating acute withdrawal symptoms.

A. "Have you noticed that your taste has decreased?" B. "Have you noticed an increase in thirst?" C. "Have you noticed unintentional weight loss?" D. "Have you noticed a ringing in your ears?"

Correct Answer is B

Explanation

Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.

Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.

Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.

Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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