What is the side effect caused by tyramine in foods when taking an MAOI inhibitor?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Hypertensive crisis. When a patient taking a monoamine oxidase inhibitor (MAOI) consumes foods high in tyramine, such as aged cheeses or cured meats, it can lead to a hypertensive crisis. Tyramine is a substance that can cause the release of norepinephrine, which can result in dangerously high blood pressure when MAOIs, which normally break down norepinephrine, are inhibited. Option A) Cardiac dysrhythmias is incorrect because tyramine does not typically cause dysrhythmias directly. Option B) Thyroid storm is unrelated to tyramine and MAOI interactions. Option D) Rhabdomyolysis is not a known side effect of tyramine in foods when taking an MAOI. Understanding the interaction between tyramine-containing foods and MAOIs is crucial for nurses and other healthcare providers to prevent potentially life-threatening complications in patients. Educating patients on dietary restrictions while taking MAOIs is essential to ensure their safety and well-being.

Correct Answer: B

Rationale: In the context of assessing a client with alcohol dependence for escalating withdrawal, the correct indicator is option B) CAGE screening test. The CAGE questionnaire is a widely used screening tool that helps identify alcohol-related problems, including withdrawal symptoms. It consists of four simple questions that can quickly assess the likelihood of alcoholism or alcohol abuse. Option A) Rule of one hundreds is not directly related to assessing escalating withdrawal in alcohol dependence. This rule typically pertains to estimating a patient's fluid requirements based on body weight and is not specific to alcohol withdrawal. Option C) Alcoholics Anonymous is a support group for individuals recovering from alcoholism and is not a tool for assessing withdrawal symptoms in a clinical setting. Option D) Rule of nines is a method used to estimate the percentage of body surface area affected by burns and is not applicable to assessing alcohol withdrawal symptoms. Educationally, understanding the appropriate tools and assessments for monitoring alcohol withdrawal is crucial for nurses caring for clients with alcohol dependence. The CAGE screening test provides a structured approach to identifying potential issues related to alcohol use, enabling early intervention and appropriate care planning. Nurses must be familiar with such screening tools to ensure comprehensive and effective care for clients with substance use disorders.

Correct Answer: B

Rationale: In the context of a client on a fluid restriction, the most appropriate nursing diagnosis is "Altered comfort: dry mouth and thirst related to restricted oral fluid" (Option B). This diagnosis addresses the specific discomfort and challenges faced by the client due to the restriction of fluid intake. Option A, "Excess fluid volume related to intake that exceeds fluid loss," is incorrect because a client on a fluid restriction is actually at risk for fluid volume deficit, not excess fluid volume. Option C, "Risk for impaired skin integrity related to compromised circulation secondary to edema," is not directly related to a fluid restriction but rather to edema and compromised circulation. Option D, "Fluid volume deficit secondary to dehydration," is close but not as specific as Option B, which directly addresses the discomfort and challenges associated with restricted oral fluid intake. In an educational context, understanding the rationale behind selecting the correct nursing diagnosis is crucial for providing effective care to clients. By choosing the appropriate diagnosis, nurses can better address the client's needs and promote optimal health outcomes. It is essential to differentiate between different nursing diagnoses to ensure accurate assessment and intervention planning based on the client's specific condition and restrictions.

Correct Answer: B

Rationale: In the context of pharmacology and shock recovery, it is crucial to understand why a client's recovery from shock can be tenuous. The correct answer is B) Edema. Explanation: Edema, or the accumulation of fluid in the interstitial spaces, can make a client's recovery from shock tenuous due to several reasons. In shock, there is inadequate tissue perfusion leading to cellular hypoxia and the release of inflammatory mediators. This can result in increased capillary permeability and fluid leakage into tissues, causing edema. Edema complicates recovery as it can impair circulation further, hinder tissue oxygenation, and increase the workload on the heart, potentially leading to heart failure. Why others are wrong: A) Increased urine output is not a characteristic that would make a client's recovery from shock tenuous. In fact, adequate urine output is often a positive sign of tissue perfusion and renal function recovery. C) Hypertension is not typically a feature of shock. Shock is characterized by hypotension due to decreased perfusion and can lead to organ dysfunction. D) Hypernatremia, an elevated serum sodium level, is not directly related to the tenuous recovery from shock. In shock, electrolyte imbalances are more commonly associated with hypovolemia and fluid shifts. Educational context: Understanding the implications of edema in shock recovery is essential for nurses and healthcare providers managing patients in critical conditions. It underscores the importance of monitoring and managing fluid balance, recognizing signs of worsening perfusion, and implementing appropriate interventions to optimize outcomes for patients in shock.

Correct Answer: C

Rationale: In the context of a client in shock, the priority nursing intervention is to address acidosis, making option C the correct answer. Shock is a life-threatening condition where there is inadequate tissue perfusion leading to cellular hypoxia and anaerobic metabolism, which results in metabolic acidosis. Addressing acidosis is crucial as it can have detrimental effects on various organ systems and exacerbate the shock state. Option A, hypoxia, is a consequence of shock but is not the immediate priority because addressing acidosis will help improve tissue oxygenation. Hypercapnia (option B) and alkalosis (option D) are not typically associated with shock and are not the primary concerns in this situation. Educationally, understanding the pathophysiology of shock and its impact on the body's acid-base balance is essential for nurses to provide effective care in emergency situations. Recognizing the priority interventions in shock can help nurses prioritize care and improve patient outcomes in critical scenarios.