A nurse is caring for a client on an acute care mental health unit.
The nurse is providing discharge education to the client about their medication. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. When educating the client about their medication, the nurse should teach the client that there is a risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
When educating the client about their medication, the nurse should teach the client that there is a risk for hypertensive crisis due to ingestion of tyramine.
Choice A: Hypertensive Crisis
Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.
Choice B: Tardive Dyskinesia
Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.
Choice C: Rhabdomyolysis
Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.
Choice D: Infection
Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.
Choice E: Nervous System Instability
Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.
Choice A: Hypertensive Crisis
Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.
Choice B: Tardive Dyskinesia
Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.
Choice C: Rhabdomyolysis
Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.
Choice D: Infection
Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.
Choice E: Nervous System Instability
Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Suppression is a conscious defense mechanism where an individual intentionally avoids thinking about disturbing thoughts or feelings. In this case, the client is choosing to delay addressing the reality of their diagnosis until after a significant family event. This can be seen as a temporary coping strategy to manage overwhelming emotions, but it may become maladaptive if overused or if it prevents the client from seeking necessary treatment and support.
Choice B reason:
Compensation involves overachieving in one area to make up for deficiencies in another. The client's statement does not suggest that they are trying to compensate for their illness by excelling in other areas of life; rather, they are postponing the emotional processing of their diagnosis.
Choice C reason:
Regression is a return to earlier stages of development and coping strategies, often under stress. The client's statement does not indicate a regression to more childlike behaviors or earlier developmental stages.
Choice D reason:
Sublimation is a way of channeling unacceptable impulses into socially acceptable actions. The client's statement does not reflect the use of sublimation, as they are not redirecting their feelings about the diagnosis into a different, more acceptable outlet.
Correct Answer is D
Explanation
Choice A reason:
Allowing the client to focus on the delusion for as long as they want is not recommended. This approach can reinforce the delusion and make it more entrenched. It is important to engage the client in reality-based activities and conversations to help them connect with the world around them.
Choice B reason:
Reinforcing the importance of controlling impulses is a general strategy that can be beneficial for clients with schizophrenia. However, it does not directly address the issue of delusions. Impulse control is more about managing behaviors that could be harmful or disruptive.
Choice C reason:
Contradicting the client's delusional beliefs can be confrontational and may lead to increased anxiety or aggression. It is generally not effective to argue with a client about their delusions because these beliefs are very real to them. The nurse should acknowledge the client's experience without agreeing with the delusion.
Choice D reason:
Asking the client to describe their beliefs about the delusion can be a therapeutic approach. It allows the nurse to understand the client's perspective and build a therapeutic relationship based on empathy and trust. This approach does not validate the delusion but rather opens a dialogue that can be used to gently challenge the delusion with evidence from the client's environment.
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