A patient for whom phenelzine (Nardil) is prescribed complains of a sudden headache and palpitations. The nurse observes dilated pupils and diaphoresis. The nurse's first action should be
a. assess for cogwheel rigidity.
b. notify the health care provider.
c. assess the patient's blood pressure.
d. withhold the morning dose of phenelzine.
C
The patient's symptoms are suggestive of hypertensive crisis. It is vital to know whether or not the blood pressure is elevated, so obtaining the blood pressure is the necessary first action. The most probable reason for the reaction would be drug–food interaction. The nurse may notify the health care provider and withhold the morning dose as subsequent actions. Cogwheel rigidity is associated with antipsychotic medications.
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With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that:
a. A newborn's skull is still forming and fractures fairly easily. b. Unless a blood vessel is involved, linear skull fractures heal without special treatment. c. Clavicle fractures often need to be set with an inserted pin for stability. d. Other than the skull, the most common skeletal injuries are to leg bones.
An adolescent female is experiencing dysmenorrhea. What should the nurse teach the patient to help with this disorder?
A) Take acetaminophen (Tylenol). B) Restrict fluid when having pain. C) Take over-the-counter ibuprofen. D) Use ice to help in reducing inflammation and pain.
Care for a patient who has had joint replacement surgery includes all of the following except
A. preventing infection. B. preventing blood clots. C. preventing extension. D. applying antiembolism hosiery.
A nurse is beginning the physical exam of a male client's genitals. The nurse is sitting on a stool in front of the client. Which position would be best to place the client in?
A) Lying supine B) Kneeling C) Standing D) Sitting