Exhibits Complete the following sentence by using the list of options. The nurse should plan to administer dropdownanddropdown
Explanation & Rationale
Intravenous phentolamine should be administered because the client is experiencing a hypertensive crisis due to the interaction between phenelzine (a monoamine oxidase inhibitor [MAOI]) and over-the-counter decongestants. MAOIs can cause severe hypertension when taken with sympathomimetic agents (such as pseudoephedrine, commonly found in decongestants). Phentolamine is an alpha-adrenergic antagonist that rapidly lowers blood pressure in hypertensive emergencies. Apply a cooling blanket to the client because the client’s temperature is dangerously high (39.6°C/103.2°F), which may indicate autonomic dysregulation or hyperthermia associated with hypertensive crisis. Active cooling measures are necessary to prevent complications such as seizures, organ damage, or stroke. Oral benztropine is used to treat extrapyramidal symptoms from antipsychotic medications but is not relevant to this client’s condition. Oral valbenazine is used to treat tardive dyskinesia, a side effect of dopamine-blocking medications, but this client is experiencing a hypertensive crisis, not movement disorders. Intravenous diphenhydramine is used for allergic reactions or dystonic reactions but does not treat hypertensive crisis or hyperthermia. Placing the client on suicide precautions is unnecessary in this scenario, as there is no indication of suicidal ideation or self-harm. Checking the client’s absolute neutrophil count is relevant for clients taking clozapine (due to the risk of agranulocytosis) but is unrelated to this case of hypertensive crisis from an MAOI interaction. Educating the client to increase their salt intake is appropriate for MAOI-induced orthostatic hypotension, but this client has severe hypertension, making this recommendation inappropriate.