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A nurse is assisting in the care of a client in an outpatient mental health clinic.

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again.

Nurses' Notes

Today:

Client states, "I'm feeling much better." They report less fatigue, even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation.

Vital Signs

Today:

Blood pressure 169/91 mm Hg

Heart rate 78/min

Respiratory rate 18/min

even though they have difficulty sleeping

experiencing more frequent headaches

Blood pressure 169/91 mm Hg

Client continues to deny any suicidal ideation

Heart rate 78/min

Respiratory rate 18/min

Answer and Explanation

The Correct Answer is ["A","B","C"]

Frequent headaches: Phenelzine, an MAOI, can cause hypertensive crisis, with one of the earliest signs being persistent or worsening headaches. Frequent headaches must be treated as a possible warning of dangerously elevated blood pressure and require immediate provider notification.
Elevated blood pressure (169/91 mm Hg): The significant rise in the client's blood pressure compared to baseline indicates new-onset hypertension. This is a serious adverse effect associated with MAOIs and signals the potential development of a hypertensive crisis, which must be urgently addressed.
Difficulty sleeping: Difficulty sleeping or insomnia is a common side effect of phenelzine and other antidepressants. Although not life-threatening, insomnia can impair recovery if untreated and should be documented and discussed with the provider to adjust management if needed.
Feeling much better: Improvement in mood and reduced fatigue are intended therapeutic outcomes of phenelzine treatment. These findings are positive signs and do not indicate an adverse reaction that needs intervention.
Heart rate 78/min and respiratory rate 18/min: Both values are within normal ranges and do not suggest immediate concerns related to cardiovascular or respiratory function. They should continue to be monitored but do not require urgent action.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Recommend frequent hot baths: Hot baths can exacerbate symptoms in clients with multiple sclerosis by increasing fatigue and worsening muscle weakness due to a rise in core body temperature. Clients are usually advised to avoid overheating and use cooling strategies instead to manage their symptoms.

B. Encourage the client to restrict performing range-of-motion exercises: Range-of-motion exercises are important in maintaining joint flexibility, muscle strength, and overall mobility. Restricting these exercises could lead to increased stiffness, weakness, and decreased functional ability in clients with multiple sclerosis.

C. Monitor the client's ability to perform ADLs: Monitoring the client's ability to perform activities of daily living is essential because multiple sclerosis often leads to progressive physical limitations. Regular assessment helps in planning appropriate interventions, promoting independence, and adjusting care as the disease progresses.

D. Initiate contact precautions: Contact precautions are not necessary for clients with multiple sclerosis because it is not an infectious disease. Multiple sclerosis is an autoimmune, neurodegenerative condition that requires supportive care rather than infection control measures.

A. "Use sunglasses if your eyes are sensitive to light." B. "Continue eating foods with protein." C. "Remain on bedrest for 3 to 5 days following discharge." D. "You need to support your neck when coughing or moving E. "You will no longer need to take any medications for your thyroid now that you have had surgery."

Correct Answer is ["A","B","D"]

Explanation

"Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
"Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
"Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
"You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
"You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?

Correct Answer is C

Explanation

The nurse has reviewed the Vital Signs at 1000. Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is assisting with the care of a client in a provider's clinic. For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

Which of the following findings requires further action by the nurse? Select all that apply.

A nurse is reinforcing teaching about foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching?

A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following images should the nurse identity as an example of a ball and socket joint?

A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

A nurse is assisting with the admission of an infant who has experienced vomiting and loose, watery stools for the past 3 days. Which of the following findings indicates that the child is experiencing moderate dehydration?

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.