The registered nurse (RN) reviews the new prescription, phenelzine, 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 o...
BSN 246 HESI Health Assessment Complete Exam
Preparation: Questions & Answers
The registered nurse (RN) reviews the new prescription, phenelzine, 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.
(Ans- A
All alcohol (A) and any foods that contain tyramine should be avoided
while taking an MAO inhibitor, which interact to cause a hypertensive
crisis. (B and C) should be discussed, but are not as important as (A).
Although assessing blood pressure and pulse may be indicated, it is not
necessary prior to taking each dose (D).
A female client is recently diagnosed with Sarciodosis. The client tells
the registered nurse (RN) that she does not understand why she has
this. When teaching about the occurrence of sarcoidosis, the RN should
include that sarcoidosis most commonly occurs with which ethnic group
of women?
A. African American women
B. Caucasian women
,C. Asian women
D. Hispanic women
(Ans- A
Sarcoidosis, an autoimmune inflammatory disease affecting multiple
organs, has shown presence in relatives due to multiple genes that
together to increase the susceptibility of developing the disease, which
most commonly occurs in African American women and women of
Northern European heritage (A). (B, C, and D) have a lower percentage
of women affected by sarcoidosis than African American women.
A client who uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should
the registered nurse (RN) implement first?
A. Withhold medication and report symptoms and vital signs to
healthcare provider.
B. Give PRN medication for nausea and vomiting and evaluate client in
30 minutes.
C. Reassure client that the ipratropium given will alleviate the
symptoms.
D. Delay administration of ipratropium until next maintenance
medication is scheduled.
(Ans- A
Headache, nausea, blurred vision and insomnia are symptoms of
excessive use of ipratropium, so withholding the medication (A) until
the healthcare provider is notified should be initiated to maintain client
,safety. If the symptoms continue and are not addressed immediately,
then (B, C, and D) may place the client in imminent danger.
A client with chest pain, dizziness, and vomiting for the last 2 hours is
admitted for evaluation for Acute Coronary Syndrome (ACS). Which
cardiac biomarker should the registered nurse (RN) anticipate to be
elevated if the client experienced myocardial damage?
A. Creatine Kinase (CK-MB)
B. Serum troponin
C. Myoglobin
D. Ischemia modified albumin
(Ans- B
Troponin (B) is the most sensitive and specific test for myocardial
damage. Troponin elevation is more specific than CK-MB (A). (C) can be
elevated when there is skeletal muscle damage. (D) can be elevated
nonspecifically and create false positives, so is not a reliable choice.
The registered nurse (RN) is caring for an older client who recently
experienced a fractured pelvis from a fall. Which assessment finding is
most important for the RN to report to the healthcare provider?
A. Lower back pain
B. Headache of 7 on scale of 1 to 10
C. Blood pressure of 140/98
, D. Dyspnea
(Ans- D
A client with a large bone fracture is at risk for intramedullary fat
leaking into the blood stream and becoming embolic. Dyspnea is an
indication of fat embolism to the lungs and should be reported to the
healthcare provider immediately. (A, B, and C) are expected findings
after a fall and do not require immediate notification of a healthcare
provider.
While caring for a client who has esophageal varices, which nursing
intervention is most important for the registered nurse (RN) to
implement?
A. Monitor infusing IV fluids and any replacement blood products
B. Prepare for esophagogastroduodenoscopy (EGD)
C. Maintain a client on strict bedrest
D. Insert a nasogastric tube (NGT) for intermittent suction
(Ans- A
Maintaining hemodynamic stability in a client with esophageal varices
can precipitate a life-threatening crisis if esophageal varies leak or
rupture and can result in hemorrhage. The priority is assessing and
monitoring infusions of IV fluids and any replacement blood products
(A). The healthcare provider should be present during (B and D) in the
event the client's esophageal varies rupture and bleed profusely.
Bedrest (C) is not a priority at this time.
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