The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a monoamine oxidase
inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most
important for the RN to assess?
A. Consumption of any alcohol or tyramine-rich foods.
B. Complaints of nausea or vomiting.
C. Therapeutic serum drug levels.
D. Blood pressure and pulse prior to taking each dose. - .......🔷ANSWERS🔶......✔✔ A.
Consumption of any alcohol or tyramine-rich foods.
Rationale
The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits
and vegetables, smoked or cured meats, dark wines and other alcoholic products should be avoided
when a client is prescribed a MAOIs due to the a food-drug interaction causing a hypertensive crisis
which can lead to a hemorrhagic stroke.
The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis.
Which assessment finding should the RN report to the healthcare provider?
A. Dry mucous membranes and lips.
B. Rebound abdominal tenderness over right lower quadrant.
C. Dizziness when client ambulates from a sitting position.
D. Poor skin turgor over client's wrist. - .......🔷ANSWERS🔶......✔✔ B. Rebound abdominal
tenderness over right lower quadrant.
Rationale
RLQ rebound abdominal tenderness may be related to acute appendicitis and should be reported to
the healthcare provider.
,The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during
conversations. How should the RN assess this client's response?
A. The client cannot understand the nurse.
B. The client is uncomfortable with the nurse.
C. The client is treating the nurse with respect.
D. The client is purposefully disrespecting the nurse. - .......🔷ANSWERS🔶......✔✔ C. The client is
treating the nurse with respect.
Rationale
In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client is
being respectful by looking down while speaking with the nurse.
The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission
laboratory results. What laboratory value should the RN anticipate being elevated with this
diagnosis?
A. Triglycerides.
B. Amylase.
C. Creatinine.
D. Uric acid. - .......🔷ANSWERS🔶......✔✔ B. Amylase.
Rationale
An elevated amylase level is associated with acute pancreatitis.
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment
findings should the RN document that are consistent with diminished peripheral circulation? (Select
all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
, E. Darkened skin on extremities. - .......🔷ANSWERS🔶......✔✔ A. Diminished hair on legs.
D. Capillary refill less than 3 seconds.
Rationale
Diminished hair on the legs and skin that is cool to touch are expectant signs of decreased arterial
blood flow.
The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests
(OGTT). Which laboratory result should the RN assess as a normal value for the two hour
postprandial result?
A. 140 mg/dl.
B. 160 mg/dl.
C. 180 mg/dl.
D. 200 mg/dl. - .......🔷ANSWERS🔶......✔✔ A. 140 mg/dl.
Rationale
The two hour postprandial level should be less 140 mg/dl for a young adult client.
The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment
should the RN identify and document that is consistent with PUD? (Select all that apply).
A. Hematemesis.
B. Gastric pain on an empty stomach.
C. Colic-like pain with fatty food ingestion.
D. Intolerance of spicy foods.
E. Diarrhea and stearrhea. - .......🔷ANSWERS🔶......✔✔ A. Hematemesis.
B. Gastric pain on an empty stomach.
D. Intolerance of spicy foods.
Rationale
Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance.
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