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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?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.
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The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy
- B. Demonstrates effective ways to cope with anxiety
- C. Learns methods of relaxation to reduce anxiety
- D. Takes all antianxiety medications as prescribed
Correct Answer: B
Rationale: This outcome directly addresses the client's maladaptive coping mechanism (scratching wrists) by aiming to replace it with healthier strategies. Therapy participation and relaxation methods are important but secondary to effective coping. Medication adherence does not teach alternative coping strategies.
The nurse continues caring for the client:
The client is a 26-year-old female who was in a car accident 6 months s ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression.
Click to indicate whether findings at the next follow-up appointment indicate that the treatment was effective or ineffective. Each row must have one response selected.
- A. The client talks to her father and her best friend when she starts to feel sad: Effective
- B. The client states she feels numb when thinking about the crash: Ineffective
- C. The client states that she avoids driving altogether and takes the bus: Effective
- D. The client reports sleeping 6 to 7 hours per night: Effective
- E. The client states she feels less jumpy and more relaxed: Effective
Correct Answer: A,B,C,D,E
Rationale: A: Seeking support is a positive coping mechanism (Effective). B: Numbness suggests unresolved trauma (Ineffective). C: Avoiding driving reduces distress (Effective). D: Adequate sleep indicates improvement (Effective). E: Reduced anxiety shows treatment efficacy (Effective).
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?
- A. Share personal values to put the client at ease
- B. Ask questions in a vague, non-specific format
- C. Begin with questions that are less sensitive in nature
- D. Get the most difficult questions over with first
Correct Answer: C
Rationale: Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation. Sharing personal values may blur professional boundaries. Vague questions may not yield accurate information. Starting with difficult questions may overwhelm the client and hinder trust.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Stimulation and dilated pupils
- B. Bradycardia and bradypnea
- C. Hallucinations and delusions
- D. Lethargy and depression
Correct Answer: A
Rationale: Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness. Bradycardia and bradypnea are not typical, as cocaine causes tachycardia and increased respiratory rate. Hallucinations and delusions are more associated with hallucinogens or psychotic disorders. Lethargy and depression occur during the 'crash' phase, not the immediate effects of cocaine use.