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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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason: Intensive Outpatient Programs (IOPs) offer structured treatment for mental health and substance misuse concerns, providing therapy for a few hours a day, several days a week. While beneficial, they may not offer the comprehensive, round-the-clock support needed by someone with a chronic mental illness.
Choice B reason: Assertive Community Treatment (ACT) is a form of community-based mental health care designed to help individuals with serious mental illnesses manage their symptoms and live independently in the community. ACT involves a multidisciplinary team approach and provides round-the-clock services, making it an ideal resource for chronic mental illness management.
Choice C reason: Patient-Centered Medical Homes (PCMHs) focus on providing comprehensive, coordinated care that is patient-centered and culturally appropriate. Although PCMHs offer a broad range of services, they may not be as intensive as ACT for managing chronic mental illness.
Choice D reason: Partial Hospitalization Programs (PHPs) are intensive outpatient treatment programs that allow patients to live at home while receiving daily treatment at a facility. PHPs are more intensive than IOPs but less so than inpatient care, and they may not provide the continuous support that ACT offers for chronic mental illness.
Correct Answer is B
Explanation
Choice A reason: Asking "Why did you feel like giving away your belongings?" could be perceived as confrontational or judgmental. It's important to approach the client with empathy and without implying that their actions were wrong or require justification.
Choice B reason: "Can you tell me how you have been feeling lately?" is an open-ended question that invites the client to share their feelings and experiences. It demonstrates the nurse's interest in understanding the client's emotional state and provides a safe space for the client to express themselves.
Choice C reason: Saying "Everyone feels a little down sometimes." minimizes the client's experience and the severity of major depressive disorder. It fails to acknowledge the unique and serious nature of the client's condition.
Choice D reason: While suggesting "You should find a support group to attend." can be helpful, it may be more appropriate after establishing a rapport and understanding the client's current state. It's also important to offer support in finding resources rather than directing the client.
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