A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

Decreased blood pressure.

Decreased heart rate.

Hyperthermia.

Hyperglycemia.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Hyperthermia.

Choice A rationale:

Decreased blood pressure is not a typical manifestation of alcohol withdrawal. Instead, clients often experience increased blood pressure due to the hyperactive state of the nervous system during withdrawal.

Choice B rationale:

Decreased heart rate is also not common in alcohol withdrawal. Clients usually have an increased heart rate (tachycardia) as part of the withdrawal symptoms.

Choice C rationale:

Hyperthermia, or elevated body temperature, can occur during alcohol withdrawal due to the hyperactive state of the nervous system. This is a serious symptom that requires monitoring and management.

Choice D rationale:

Hyperglycemia is not typically associated with alcohol withdrawal. Blood sugar levels can fluctuate, but hyperglycemia is not a primary concern in this context.

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Correct Answer is C

No explanation

A. Bowel sounds. B. Blood pressure. C. Oxygen saturation. D. Pupil response.

Correct Answer is B

Explanation

The correct answer is Choice b, Blood pressure.

Rationale for Choice a, Bowel sounds:

Bowel sounds are not directly relevant to the potential interaction between phenelzine and pepperoni pizza.
While assessing bowel sounds is a part of a comprehensive nursing assessment,it would not be the top priority in this specific scenario.
Phenelzine does not typically cause gastrointestinal disturbances that would warrant immediate assessment of bowel sounds.

Rationale for Choice c, Oxygen saturation:

Oxygen saturation is not directly affected by the interaction between phenelzine and pepperoni pizza.
Assessing oxygen saturation would be more pertinent in situations involving respiratory distress or hypoxia.
There is no evidence to suggest that this interaction would cause respiratory depression or compromise oxygen saturation levels.

Rationale for Choice d, Pupil response:

Pupil response is not a reliable indicator of the potential complications associated with phenelzine and tyramine-rich foods.
It's primarily assessed for neurological conditions or drug intoxication affecting the central nervous system.
The interaction between phenelzine and tyramine primarily affects the cardiovascular system,not the neurological system.

Rationale for Choice b, Blood pressure:

Blood pressure is the most critical assessment in this scenario due to the potential for a hypertensive crisis.
Phenelzine is a monoamine oxidase inhibitor (MAOI),which blocks the breakdown of tyramine,a substance found in certain foods like pepperoni,aged cheeses,and fermented products.
When tyramine levels increase,it can trigger a sudden and severe rise in blood pressure,known as a hypertensive crisis.
Symptoms of a hypertensive crisis can include:
- Severe headache
- Neck stiffness
- Chest pain
- Nausea
- Vomiting
- Blurred vision
- Sweating
- Photophobia (sensitivity to light)
- Palpitations
- Anxiety
- Confusion
- Seizures
- Stroke
- Potentially death
Prompt assessment of blood pressure is crucial for early detection and intervention to prevent these life-threatening complications.

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A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought-stopping technique?

Correct Answer is C

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

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