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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Restricting visitors may exacerbate feelings of isolation and may not be therapeutic for the adolescent client who is depressed.
B. Reinforcing statements regarding a will to live and realistic plans for the future can provide hope and motivation for the adolescent to engage in treatment and recovery.
C. Understanding the client's suicide plan is crucial for assessing risk and planning appropriate interventions to ensure safety.
D. Encouraging the client to discuss thoughts and feelings promotes open communication and allows the adolescent to express emotions, which can be therapeutic and supportive in managing depression.
E. While limiting excessive screen time, including video games, may be beneficial for overall well-being, it may not directly address the underlying issues contributing to the adolescent's depression and may be less relevant in the immediate plan of care.
Correct Answer is D
Explanation
Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.
Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.
Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.
Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.
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