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 A

Explanation

A. Providing a quiet room is important. This is because individuals with PTSD are often hypersensitive to noise and other stimuli, which can trigger flashbacks or other
symptoms. A quiet environment can help to reduce anxiety and promote relaxation.
B. Acquainting the client with the unit rules is important, but connecting the client with peers who understand their experiences can be more therapeutic initially.
C. Ensuring a well-balanced diet is essential but might not be the priority in the immediate plan of care for someone newly admitted with PTSD.
D. Introducing the client to others with similar diagnoses helps foster a sense of belonging.
However, this is a long-term rather than an immediate intervention.

A. Ask another nurse to talk with the client. B. Document the client's paranoid behavior. C. Postpone the client interview until the next day. D. Attempt to ask the client simple questions.

Correct Answer is D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

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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 with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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