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 D

Explanation

A. Clients taking disulfiram must completely avoid alcohol, as even small amounts can cause severe reactions (e.g., nausea, vomiting, flushing, hypotension). There is no safe amount of alcohol to consume while on this medication.
B. Alcohol consumption must be completely avoided, not just limited, while taking disulfiram, as the drug works by causing an aversive reaction when alcohol is ingested.
C. Disulfiram should not be started immediately if alcohol is still in the system. It must be initiated at least 12–48 hours after the last drink to prevent severe reactions.
D. The client should begin taking disulfiram at least 48 hours after the last alcohol intake to reduce the risk of adverse effects. The medication is taken daily, and alcohol must be strictly avoided, including in hidden sources like mouthwash and cooking extracts.

A. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent. B. Both the nurse and therapist are reprimanded for divulging confidential patient information to others. C. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information. D. The therapist is reprimanded for divulging confidential patient information without obtaining consent.

Correct Answer is C

Explanation

A. The nurse acted appropriately by disclosing information to the therapist and other team members to ensure the client's safety and well-being. However, educating other team members on appropriate sharing of client information may be necessary to ensure consistency and adherence to privacy laws and ethical guidelines.
B. Both the nurse and therapist acted in the client's best interest by sharing relevant information with appropriate team members to ensure safety. However, reprimanding them may not be warranted if their actions were based on concerns for the client's safety.
C. This outcome acknowledges the importance of educating team members on confidentiality and appropriate sharing of client information to maintain trust and privacy while ensuring client safety.
D. While the therapist did share confidential information with the client's supervisor, it was done in the context of ensuring the safety of all involved parties. Therefore, reprimanding the therapist may not be appropriate in this situation.

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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

Naxlex Comprehensive Predictor Exams

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

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