A client comes to the emergency department complaining of a severe pounding headache in the temples and a stiff neck. The client is flushed and diaphoretic, and his pulse is racing. The client states that he is being treated for depression with selegiline

Question

Which question by the nurse would be most important to ask at this time?

A) "When did you last have blood drawn to check your drug level?"
B) "What have you had to eat or drink today?"
C) "Are you having any chest pain?"
D) "Do you use any herbal remedies?"

Answer 1

Ans: B
The client is exhibiting signs of a hypertensive crisis, which can occur when a client is receiving MAOI therapy (selegiline) and ingests food or other substances that contain tyramine. Thus the nurse should ask the client what he has had to eat or drink. Drug levels are used to monitor tricyclic antidepressants. Asking about chest pain would be appropriate after obtaining information related to what the client has ingested. Herbal remedies can interact with medications, but this information would be obtained after determining whether the client has ingested foods and fluids containing tyramine.