In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Blood pressure.

Urinary output.

Respiratory rate.

Temperature.

Answer and Explanation

The Correct Answer is A

Rationale:
A.   MAO inhibitors such as phenelzine can cause significant fluctuations in blood pressure, including hypertensive crisis when combined with certain foods or medications. Therefore, monitoring blood pressure is crucial to detect and prevent hypertensive emergencies.
B.   While monitoring urinary output is important for overall assessment, it is not specifically associated with the use of MAO inhibitors like phenelzine.
C.   Respiratory rate is not typically affected by MAO inhibitors like phenelzine and may not be the most relevant assessment finding in this scenario.
D.   Temperature monitoring is important for general assessment but is not specifically associated with the use of MAO inhibitors like phenelzine.

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Correct Answer is A

Explanation

A. The CAGE questionnaire focuses on four key aspects related to alcohol use: efforts to Cut down, Annoyance with questions about drinking, feelings of Guilt about drinking, and using alcohol as an "Eye-opener" in the morning. Exploring these aspects in depth can provide valuable information about the client's relationship with alcohol and potential problems.

B. While information about consumption, liver enzymes, and gastrointestinal complaints is important for assessing alcohol-related issues, these are not specifically addressed by the CAGE questionnaire.
C. Cancer screening results, anger, gastritis, and daily alcohol intake are relevant to assessing the client's overall health and alcohol use but are not directly related to the questions asked in the
CAGE questionnaire.
D. While information about minimizing drinking, missing family events, guilt about drinking, and daily alcohol intake may provide insight into the client's alcohol use, these aspects are not specifically addressed by the questions in the CAGE questionnaire.

A. Nausea and vomiting. B. Short-term memory loss. C. Five-pound (2.3 kg) weight gain. D. Depressed affect.

Correct Answer is A

Explanation

A. Nausea and vomiting could indicate potential lithium toxicity, which requires immediate medical attention to prevent serious complications.
B. Short-term memory loss is a known side effect of lithium therapy but may not require immediate medical attention unless severe or persistent.
C. Weight gain is a common side effect of lithium, but a five-pound (2.3 kg) gain may not be considered significant enough to warrant immediate medical attention unless it occurs rapidly or is accompanied by other symptoms.
D. Depressed affect is a symptom of depression and may be related to the client's underlying condition but may not require immediate medical attention unless it poses a risk to the client's safety.

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In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Nursing Test Bank

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