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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 B

Explanation

A. Black out the line with a felt-tip pen: Blacking out a space or entry is inappropriate because it obscures the original documentation, making the record appear altered or falsified. Medical documentation must remain clear, transparent, and legally defensible at all times.

B. Draw a horizontal line through the space and sign at the end of the line: Drawing a single horizontal line through the blank space ensures that no unauthorized additions can be made later. Signing at the end of the line maintains the integrity and completeness of the medical record, following accepted documentation standards.

C. Place the date at the beginning of the space, followed by double lines: Simply dating the space without properly securing it with a line could leave it open to later insertions. Double lines are also not a recognized standard method for handling blank spaces in documentation.

D. Leave the space as it is within the entry: Leaving a blank space unmarked can create opportunities for someone to add unauthorized information later. This poses legal and ethical risks and compromises the reliability and security of the medical record.

A. Notifying the caregiver of the findings. B. Including findings during hand-off report. C. Documenting suspicions in the client's medical record D. Reporting findings to social services.

Correct Answer is D

Explanation

A. Notifying the caregiver of the findings: If the caregiver is potentially involved in abuse or neglect, informing them directly could put the client at further risk. The nurse must follow appropriate reporting channels rather than confront the caregiver.

B. Including findings during hand-off report: While communication during hand-off is important for continuity of care, it does not fulfill the nurse’s legal obligation to formally report suspected abuse or neglect to the appropriate authorities.

C. Documenting suspicions in the client's medical record: Accurate and objective documentation of findings is important, but simply recording observations in the medical record does not meet the legal responsibility to report suspected abuse.

D. Reporting findings to social services: Nurses are mandated reporters and must legally report suspected abuse or neglect to the appropriate protective services. Reporting ensures that an investigation can occur to protect the client from further harm.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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