A nurse is caring for a client in the outpatient health clinic.
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
Instruct client to avoid foods that have been fermented or aged.
Encourage client to sleep until later in the morning.
Advise client to notify provider if pregnant.
Encourage high-calorie finger foods.
Advise client to rise slowly from sitting position.
Encourage naps during the day when client is tired.
Encourage a regular sleep-wake schedule.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Rationale:
- Instruct client to avoid foods that have been fermented or aged: This dietary restriction applies to monoamine oxidase inhibitors (MAOIs), not trazodone, which is a serotonin antagonist and reuptake inhibitor (SARI).
- Encourage client to sleep until later in the morning: Oversleeping can disrupt circadian rhythms and worsen fatigue. A consistent, balanced sleep schedule is more therapeutic.
- Advise client to notify provider if pregnant: Trazodone is a category C medication and should only be used in pregnancy if the benefits outweigh the risks. The provider must be informed if the client is or may become pregnant.
- Encourage high-calorie finger foods: The client has experienced weight loss and decreased appetite. Nutrient-dense, easy-to-eat foods can support caloric intake without requiring full meals.
- Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension. Educating the client to change positions slowly helps prevent dizziness and potential falls.
- Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep and may reduce trazodone’s effectiveness in establishing a healthy sleep pattern.
- Encourage a regular sleep-wake schedule: Trazodone is often prescribed for sleep difficulties. A consistent routine supports sleep hygiene and enhances the medication’s effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Polydipsia: Polydipsia, or excessive thirst, is commonly associated with hyperglycemia due to osmotic diuresis caused by high blood glucose levels. It is not a typical feature of hypoglycemia.
B. Tremors: Tremors are a hallmark symptom of hypoglycemia. They result from the body's adrenergic (sympathetic) response to low blood glucose levels, which triggers the release of epinephrine to raise glucose.
C. Acetone breath odor: A fruity or acetone breath odor is associated with diabetic ketoacidosis, a complication of hyperglycemia, not hypoglycemia. It indicates ketone buildup due to fat metabolism in the absence of insulin.
D. Inability to concentrate: Cognitive impairment, such as confusion or difficulty concentrating, is a neurological symptom of hypoglycemia. The brain relies heavily on glucose, and low levels affect its function quickly.
E. Diaphoresis: Sweating is a common autonomic symptom of hypoglycemia due to activation of the sympathetic nervous system. It often occurs early in a hypoglycemic episode and is a critical sign to monitor.
Correct Answer is A
Explanation
Rationale:
A. Smoked salmon: Smoked and aged foods are high in tyramine, which can interact dangerously with phenelzine, a monoamine oxidase inhibitor (MAOI). This interaction can trigger a hypertensive crisis, making smoked salmon a food to avoid during therapy.
B. Cottage cheese: Cottage cheese contains low levels of tyramine compared to aged cheeses and is generally considered safe for clients taking MAOIs like phenelzine. It does not pose a significant risk for hypertensive crisis.
C. Grapefruit: Grapefruit can interact with many medications by affecting liver enzymes, but it does not have a known interaction with phenelzine. The concern with phenelzine is primarily with tyramine-rich foods, not citrus fruits.
D. Spinach: Spinach is not high in tyramine and does not interact with MAOIs. It is a leafy green that is safe and healthy for clients to consume while on phenelzine.
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