ATI RN Mental Health and Psychiatric NursingTestbank with answers & Rationale(Comprehensive Mental Health and Psychiatric Nursing)
(Set 9)
1. After
... [Show More] administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor thefemale client carefully for which of the following?
A. Respiratory depression
B. Epilepsy
C. Kidney failure
D. Cerebral edema
Correct Answer: A. Respiratory depression
After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefullybecause the drug is short-acting & respiratory depression may recur after its effects wear off. Oncethepharmacological effects of naloxone have worn off, there is a possibility that respiratory depressionmayrecur, and without monitoring, this could spell real trouble for the patient. Option B: Naloxone has few side effects. The most common are those of acute withdrawal fromopioids, such as anxiety, aggression, nausea, vomiting, diarrhea, abdominal pain, and rhinorrhea. Inrare cases, the use of naloxone can precipitate noncardiogenic pulmonary edema. The incidenceof
naloxone-induced noncardiogenic pulmonary edema is estimated to be between 0.2%and 3.6%of
patients who have received naloxone and are transported to the emergency department. Option C: In chronic opioid users, naloxone requires slow administration to individuals who aredependent on opioids. All patients who have responded to naloxone should be continuously
monitored for at least six to 12 hours since some opioids (methadone, fentanyl, buprenorphine)
have a much longer half-life than naloxone. The half-life of naloxone in adults varies from30 to80minutes. The patient should have vital signs, including pulse oximetry, monitored until obtainingafull recovery. Option D: Symptoms include persistent hypoxia, despite the resolution of respiratory depressionsecondary to acute overdose. Patients may also have a cough productive of the classic “pink, frothysputum” indicative of pulmonary edema. Chest radiography will be consistent with the findings of
pulmonary edema. It bears mention that the onset of noncardiogenic pulmonary edema occurs
within 4 hours in most patients. However, there have been case reports of delayed onset of upto8hours after naloxone administration. 2. When teaching Mario with a typical depression about foods to avoid while taking
phenelzine(Nardil), which of the following would the nurse in charge include?
A. Roasted chicken
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B. Fresh fish
C. Salami
D. Hamburger
Correct Answer: C. Salami
Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided becausewhen they are ingested in combination with MAOIs a hypertensive crisis will occur. MAOIs prevent thebreakdown of tyramine found in the body as well as certain foods, drinks, and other medications. Patients that take MAOIs and consume tyramine-containing foods or drinks will exhibit high serumtyramine level. A high level of tyramine can cause a sudden increase in blood pressure, called the
tyramine pressor response. Even though it is rare, a high tyramine level can trigger a cerebral
hemorrhage, which can even result in death [Show Less]