Answer to Question 1
Correct Answer: 1
Rationale 1: Assessing the client's blood pressure is appropriate because Chianti wine is high in dietary tyramine. This can result in a hypertensive crisis when combined with an MAOI drug. So the nurse must check the client's blood pressure. It is important to discuss the effects of alcohol and antidepressants, but physiological assessment takes priority over education.
Rationale 2: Discussing the effects of wine on the action of antidepressants is incorrect because while it is important to discuss the effects of alcohol and antidepressants, physiological assessment takes priority over education. Likewise, alcohol can increase the symptoms of depression, but physiological assessment takes priority over education.
Rationale 3: Arranging for admittance to the psychiatric unit is incorrect because admittance to the psychiatric unit is not appropriate at this time; there is no evidence that the client is suicidal.
Rationale 4: Discussing how wine can increase the symptoms of depression is incorrect because while alcohol can increase the symptoms of depression, physiological assessment takes priority over education.
Global Rationale: Assessing the client's blood pressure is appropriate because Chianti wine is high in dietary tyramine. This can result in a hypertensive crisis when combined with an MAOI drug. So the nurse must check the client's blood pressure. It is important to discuss the effects of alcohol and antidepressants, but physiological assessment takes priority over education. Discussing the effects of wine on the action of antidepressants is incorrect because while it is important to discuss the effects of alcohol and antidepressants, physiological assessment takes priority over education. Likewise, alcohol can increase the symptoms of depression, but physiological assessment takes priority over education. Arranging for admittance to the psychiatric unit is incorrect because admittance to the psychiatric unit is not appropriate at this time; there is no evidence that the client is suicidal. Discussing how wine can increase the symptoms of depression is incorrect because while alcohol can increase the symptoms of depression, physiological assessment takes priority over education.
Answer to Question 2
Correct Answer: 4
Rationale 1: Is your child having problems at school? is incorrect because although school problems could be related to insomnia, the nurse should assess for side effects of the medication.
Rationale 2: Do you give the medication with food? is incorrect because there is no relationship between the side effect of insomnia and the intake of food.
Rationale 3: Does your child have sleep apnea? is incorrect because sleep apnea is uncommon in children.
Rationale 4: Stimulants such as methylphenidate cause insomnia. It is important for the nurse to know when the drug is taken. Methylphenidate should be taken early in the day to prevent insomnia.
Global Rationale: Stimulants such as methylphenidate cause insomnia. It is important for the nurse to know when the drug is taken. Methylphenidate should be taken early in the day to prevent insomnia. Is your child having problems at school? is incorrect because although school problems could be related to insomnia, the nurse should assess for side effects of the medication. Do you give the medication with food? is incorrect because there is no relationship between the side effect of insomnia and the intake of food. Does your child have sleep apnea? is incorrect because sleep apnea is uncommon in children.
The nurse cares for the postop client in the postanesthesia care unit (PACU).
A physician is performing a colonoscopy on a client and viewing the internal structures of the colon
Example of simplified note for one-time client.
Testing client’s ability to identify dull sensation
Testing patellar reflex, client in a supine position