Difficulty: Medium
Average Score: 81%
Simulated
The client is prescribed phenelzine (Nardil). The client tells the nurse that they consumed two glasses of Chianti (red) wine at lunchtime. What is the nurse's priority action?
Correct answer
D
Rationale
The correct answer is D: Assess the client's blood pressure. Phenelzine is an MAOI antidepressant that can interact dangerously with tyramine-rich foods like red wine, causing a hypertensive crisis. By assessing the client's blood pressure, the nurse can quickly identify any potential hypertensive crisis and intervene promptly.
A: Discussing how food can increase symptoms of depression is not the priority when facing a potential drug interaction crisis.
B: Arranging for admittance to the psychiatric unit is premature without assessing the client's condition first.
C: While discussing the effects of wine on the action of antidepressants is important, assessing the client's blood pressure takes precedence in this situation.
A: Discussing how food can increase symptoms of depression is not the priority when facing a potential drug interaction crisis.
B: Arranging for admittance to the psychiatric unit is premature without assessing the client's condition first.
C: While discussing the effects of wine on the action of antidepressants is important, assessing the client's blood pressure takes precedence in this situation.