Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Sexual behaviors

Frequency of hospitalizations

Sodium level

Hepatitis Viral Study (HAA) results

Answer and Explanation

Correct Answer : C,D

Choice C rationale:

Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.

Rationale for Immediate

Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.

Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.

Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.

Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.

Choice D rationale:

Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.

Rationale for Immediate

Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).

Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.

Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.

Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.

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Correct Answer is A

Explanation

Choice A rationale:

Ideas of reference are a type of delusion in which a person believes that unrelated events, objects, or actions in the environment have personal significance or meaning specifically directed towards them. In this case, the client with schizophrenia misinterpreted the group's laughter as mockery directed specifically at them, even though the story was unrelated to them.

Here's a detailed explanation of why the other choices are incorrect: B. Grandeur:

Grandiosity involves an inflated sense of self-importance, power, or identity. It's not evident in this scenario, as the client isn't expressing beliefs of exceptional abilities or status. C. Somatic delusion:

Somatic delusions focus on bodily functions or sensations, such as believing organs are rotting or insects are crawling under the skin. The client's outburst isn't related to bodily concerns. D. Erotomania:

Erotomania is a delusion where a person believes someone of higher status is in love with them. It's not applicable in this situation as the client's belief isn't about romantic interest.

A. Shellfish B. Milk C. Canned tuna D. D. Aged cheese

Correct Answer is D

Explanation

Choice A rationale:

Shellfish is generally safe for clients taking MAOIs. However, it's important to ensure shellfish is fresh and properly refrigerated to avoid tyramine buildup due to spoilage.

Some individuals with shellfish allergies may need to avoid it regardless of MAOI use.

Choice B rationale:

Milk and milk products are typically safe for clients taking MAOIs.

However, some aged cheeses, such as cheddar, Swiss, and Parmesan, can contain high levels of tyramine and should be avoided.

Choice C rationale:

Canned tuna is generally safe for clients taking MAOIs.

However, it's essential to check labels carefully, as some brands may contain added tyramine-rich ingredients like soy sauce or fermented flavorings.

Choice D rationale:

Aged cheeses contain high levels of tyramine, an amino acid that can interact with MAOIs and cause a hypertensive crisis.

This is a potentially life-threatening condition characterized by a sudden and severe increase in blood pressure.

It's crucial for clients taking MAOIs to avoid all aged cheeses, including cheddar, Swiss, Parmesan, blue cheese, feta, and others.

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Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning. The nurse has reviewed the client’s electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is reinforcing dietary teaching with a client who has a new prescription for a monoamine oxidase Inhibitor (MAOI). Which of the following foods should the nurse instruct the client to avoid while taking an MAOI?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has a history of depression about a new prescription for fluoxetine. Which statement by the client indicates understanding of the teaching?

A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?

A nurse in an acute care mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following is the nurse’s priority intervention?

A nurse is contributing to the care plan for a newly admitted client suffering from severe depressive disorder. Which of the following interventions should the nurse incorporate into the plan?

A nurse in an acute care mental health facility is caring for a client who begins to yell and scream at staff members. Which of the following actions is the nurse’s priority?

A nurse is assisting with the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse recommend to include?

A nurse in an acute care mental health facility is caring for a client who has major depression and states, “Everyone will be much better off when I’m gone.” Which of the following actions should the nurse take first?

A nurse is caring for a client who has schizophrenia and notices changes in the client’s behavior. Which of the following behaviors is the nurse’s priority to report to the provider?

Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)