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Zorluk: ZorPharmacological Therapies

During an outpatient clinic visit, a client who has been taking the monoamine oxidase inhibitor (MAOI) tranylcypromine for depression reports experiencing a sudden, throbbing headache and a "racing heart." The practical nurse obtains a blood pressure reading of 218/124 mmHg218/124 \text{ mmHg} and a heart rate of 112 beats/min112 \text{ beats/min}. Which of the following actions should the practical nurse take? (Select all that apply.)

  1. Stay with the client, place them in a semi-Fowler's position, and immediately notify the registered nurse or healthcare provider.Cevap
  2. Collect data regarding the client's dietary intake of aged cheeses, cured meats, or draft beer over the last 24 hours.Cevap
  3. Ask the client if they have used any over-the-counter nasal decongestants or cold medications recently.Cevap
  4. D
    Administer a prescribed as-needed oral dose of acetaminophen to treat the client's severe headache.
  5. E
    Prepare to independently administer a rapid-acting intravenous push antihypertensive medication to lower the blood pressure.
  6. F
    Quickly administer an available oral antihypertensive medication without checking the client's identification band due to the emergent situation.

Cevap

The correct actions are to stay with the client and notify the registered nurse, assess for recent tyramine consumption, and ask about the use of over-the-counter sympathomimetic medications.
The client is experiencing an MAOI-induced hypertensive crisis, a medical emergency characterized by extreme blood pressure elevation and a throbbing headache. The practical nurse must prioritize safety by staying with the client, positioning them safely, and notifying the provider. Furthermore, gathering data about tyramine intake and over-the-counter sympathomimetic drugs is essential, as these are the primary triggers for this drug interaction.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and current medications.
The client is taking an MAOI and presenting with a severely elevated blood pressure, tachycardia, and a throbbing headache, which strongly indicates a hypertensive crisis.
Recognizing the pattern of a critical adverse drug reaction is the first step in prioritizing care.
2
Determine appropriate immediate interventions within the practical nurse scope.
The nurse must stay with the client, elevate the head of the bed to reduce intracranial pressure, and escalate the emergency to the registered nurse or healthcare provider.
A hypertensive crisis is a life-threatening event requiring advanced medical intervention beyond the practical nurse's independent scope.
3
Identify data collection priorities to find the cause of the crisis.
The nurse should ask the client about common triggers, specifically the consumption of tyramine-rich foods or sympathomimetic medications (like decongestants).
Identifying the trigger helps the healthcare team confirm the diagnosis and prevent future occurrences once the client is stabilized.
4
Recognize and avoid unsafe or out-of-scope practices.
The nurse must not bypass safety protocols (like patient identification) or attempt to administer intravenous push medications.
Maintaining fundamental safety standards and adhering to scope of practice prevents further harm to the client.

Anahtar Kavram

MAOI Hypertensive Crisis and Practical Nurse Scope of Practice
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Konular

Pharmacological Therapies

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