A nurse is providing dietary teaching to a client who has a new prescription for phenelzine.

Which of the following food recommendations should the nurse make? (Select all that apply.)

Broccoli

Yogurt

Pepperoni pizza

Cream cheese

Bologna sandwich

Answer and Explanation

Correct Answer : A,B

- A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- D: Cream cheese is a dairy product that contains little or no tyramine and is therefore, safe in a client taking phenelzine.

- E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.

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Correct Answer is A

Explanation

- A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a lifethreatening complication that involves seizures.

- B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.

- C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.

- D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.

A. Assess the client's IV site every 8 hr. B. Check the client's WBC count every 48 hr. C. Monitor the client's mouth every 8 hr. D. Change the client's IV tubing every 48 hr.

Correct Answer is C

Explanation

- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.

- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.

- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\

- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.

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A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A nurse is providing dietary teaching to a client who has a new prescription for phenelzine.

Which of the following food recommendations should the nurse make? (Select all that apply.)