Difficulty: Medium
Average Score: 85%
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 in this scenario is checking the client's blood pressure (Choice B). Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression, and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis due to the interaction between tyramine and MAOIs. Monitoring blood pressure is crucial to detect any hypertensive crisis early on. Assessing bowel sounds (Choice A), oxygen saturation (Choice C), and pupil response (Choice D) are not directly related to the potential hypertensive crisis caused by the interaction between phenelzine and tyramine.