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 B

Explanation

A. While participation in therapy may be beneficial, the most important consideration with lithium therapy is monitoring serum levels to ensure therapeutic efficacy and avoid toxicity.
B. Lithium therapy requires regular monitoring of serum levels to maintain therapeutic efficacy and prevent toxicity, especially during times of transition or stress such as starting college
C. While it is important for the client to be aware of the signs and symptoms of his illness, routine monitoring of serum lithium levels is more crucial for maintaining stability while living away from home.
D. While independence is a positive goal, the focus in this scenario should be on ensuring the client's safety and stability through appropriate monitoring of lithium levels.

A. I hear you say you worry about causing your mother's distress. B. Are you afraid that your mother's depression will lead to her death? C. What do you think you did that led to your mother's depression? D. You are not alone in feeling responsible for others in your family. E. You are not alone in feeling responsible for others in your family.

Correct Answer is A

Explanation

A. This response acknowledges the daughter's feelings without making assumptions or placing blame, fostering open communication and understanding within the family group.
B. This response may escalate the daughter's anxiety and is not directly related to her statement about causing her mother's depression.
C. This response may inadvertently encourage the daughter to blame herself for her mother's depression, which is not helpful in addressing family dynamics.
D. This response may put the daughter on the spot and could make her feel defensive or misunderstood, hindering effective communication within the family group.

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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?

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Naxlex Comprehensive Predictor Exams

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

Correct Answer is B

Explanation

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?

Correct Answer is A

Explanation

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