A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?
- A. Pan-seared catfish.
- B. Pepperoni pizza.
- C. Deep-fried shrimp.
- D. Beef strips with gravy.
Correct Answer: D
Rationale: When a client is taking MAO inhibitors like phenelzine, foods containing tyramine should be avoided. Tyramine-rich foods can interact with MAO inhibitors and lead to a hypertensive crisis. Beef strips with gravy contain tyramine, making choice D the correct answer. Choices A, B, and C do not contain high levels of tyramine and are not specifically contraindicated with MAO inhibitors.
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A client with obsessive-compulsive disorder (OCD) is undergoing behavioral therapy. Which outcome should the nurse recognize as an indication that the client is responding positively to therapy?
- A. The client reports increased frequency of obsessive thoughts.
- B. The client demonstrates a decrease in compulsive behaviors.
- C. The client expresses a desire to leave therapy early.
- D. The client avoids participating in exposure tasks.
Correct Answer: B
Rationale: A decrease in compulsive behaviors is a positive response to behavioral therapy for OCD. Behavioral therapy aims to reduce these behaviors and promote healthier coping mechanisms. Option A, reporting an increased frequency of obsessive thoughts, would indicate a lack of improvement or worsening of symptoms. Option C, expressing a desire to leave therapy early, suggests resistance or dissatisfaction with therapy. Option D, avoiding participation in exposure tasks, goes against the principles of exposure therapy, which is commonly used in OCD treatment to help clients confront their fears and reduce anxiety.
A client diagnosed with obsessive-compulsive disorder (OCD) engages in repetitive hand washing that lasts for several hours. Which strategy should the nurse use to manage this behavior?
- A. Encourage the client to continue the behavior to alleviate anxiety.
- B. Establish a routine schedule for hand washing.
- C. Gradually reduce the amount of time spent on the behavior.
- D. Ignore the behavior as much as possible.
Correct Answer: C
Rationale: In managing obsessive-compulsive disorder (OCD), it's crucial to gradually reduce the compulsive behavior to help the client learn to manage anxiety in a structured manner. Encouraging the client to continue the behavior (Choice A) would reinforce the cycle of compulsions. While establishing a routine schedule (Choice B) may provide some structure, it doesn't address the core issue of excessive hand washing. Ignoring the behavior (Choice D) may lead to worsening symptoms and does not help the client in managing their OCD effectively.
The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client's recovery?
- A. Support group meetings.
- B. Vitamin B and multivitamin supplements.
- C. Diet with adequate calories and protein.
- D. Alcohol abstinence.
Correct Answer: D
Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening result and gastritis daily alcohol intake.
- B. Consumption, liver enzyme gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an eye-opener.
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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