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?

Urinary output.

Blood pressure.

Respiratory rate.

Temperature

Answer and Explanation

The Correct Answer is B

A.   Urinary output might be important in some contexts but is not the priority related to the use of MAO inhibitors.
B.   MAO inhibitors like phenelzine can affect blood pressure significantly; monitoring BP is crucial due to the risk of hypertensive crisis when certain foods or medications are taken.
C.   Respiratory rate might be a consideration in some situations but is not directly affected by MAO inhibitors.
D.   Temperature is not typically a primary concern related to MAO inhibitor use; blood pressure monitoring is more crucial due to potential interactions.

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Correct Answer is C

Explanation

A. A five-pound weight gain could be significant but might not require immediate reporting unless it continues to increase rapidly.
B. A depressed affect is concerning but may not warrant immediate reporting unless it signals a severe change in the client's mental state.
C. Nausea and vomiting could indicate lithium toxicity, a serious side effect requiring immediate attention and evaluation by the healthcare provider.
D. Short-term memory loss can be a side effect of lithium but might not pose an immediate threat unless severe or rapidly worsening.

A. Discuss checking the time frequently. B. Determine the type and size of the locks. C. Plan a list of activities to be carried out daily D. D Ask the client why she checks the locks.

Correct Answer is C

Explanation

A. Discussing checking the time might not address the underlying behavior but could be explored as part of understanding the client's routines.
B. Determining the locks' type and size might be relevant but might not address the behavior's root cause.
C. Planning daily activities is important and can help her manage her time effectively.
D. Asking the client why she checks the locks may not hep in addressing the underlying issue.

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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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