Difficulty: Medium
Average Score: 87%
Simulated
A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?
Correct answer
B
Rationale
The correct assessment the nurse should perform is B: Blood pressure. Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Monitoring the client's blood pressure is crucial to assess for any sudden increases that could indicate a potential crisis. Bowel sounds (choice A), oxygen saturation (choice C), and pupil response (choice D) are not directly related to the potential side effect of consuming tyramine-rich foods.