1. A nurse is reinforcing teaching to a client who has a new
prescription for phenelzine. The nurse should instruct the client that
eating foods high in tyramine can cause which of the following adverse
reactions with this medication?
A. Hypertensive crisis
B. Serotonin syndrome
C. Hearing loss
D. Urinary incontinence: A. Hypertensive crisis
RAT: Tyramine can cause severe hypertension in clients who are taking
phenelzine, a monoamine oxidase inhibitor. Manifestations include
palpitations, stiff neck, headache, nausea, vomiting, and elevated
temperature.
2. A nurse is contributing to the plan of care for a client who has antisocial
personality disorder. Which of the following short-term goals should the
nurse recommend be included in the plan?
,The client will participate in assertiveness training.
The client will discuss feelings that cause hostility.
The client will describe an activity they found enjoyable.
The client will dress in a manner appropriate for the setting and temperature.
: The client will discuss feelings that cause hostility.
RAT: Clients who have antisocial personality disorder are frequently
aggressive and are at risk for injuring themselves or others. A short-term
goal for these clients should be to discuss feelings that precipitate
aggression or hostility.
3. The nurse is assisting with an admission have a client who has eating
disorder. During data collection, which is the following to the nurse
identify as manifestations of bulimia nervosa? SOA
A. Tooth erosion
B. Hand calluses
C. Lanugo
D. Amenorrhea
E. Hypokalemia: A. Tooth erosion
,B. Hand calluses
E. Hypokalemia
RAT: Tooth erosion is a manifestation of bulimia nervosa that results from
self-in-
, duced vomiting. Hand calluses are a manifestation of bulimia nervosa
that results from self-induced vomiting. Lanugo is a manifestation of
anorexia nervosa that results from starvation. Amenorrhea is a
manifestation of anorexia nervosa that results from extreme weight
loss. Hypokalemia is a manifestation of bulimia nervosa that results
from volume depletion due to self-induced vomiting or excessive
diuretic and laxative use.
4. A nurse is caring for a client who is taking lithium and reports
persistent nausea and vomiting for 2 days. Which of the following
laboratory values should the nurse report to the provider?
A. Potassium 4.0 mEq/L
B. Lithium 0.9 mEq/L
C. BUN 12 mg/dL
D. Sodium 132 mEq/L: D. Sodium 132 mEq/L
RAT: The nurse should identify that a sodium level of 132 mEq/L is not
within the expected reference range of 136 to 145 mEq/L. This finding
indicates hyponatremia, which can lead to lithium accumulation and
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