The nurse receives handoff report on 4 clients. Which client should the nurse assess first?

Question

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Monoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs (Option C). (Option A) Buspirone, an anxiolytic medication, and diphenhydramine, an antihistamine and anticholinergic, commonly cause dry mouth. This adverse effect is inconvenient but does not pose a risk to the client. (Option B) Beta blockers, such as metoprolol, and ACE inhibitors, such as lisinopril, are used to treat hypertension. These medications commonly cause orthostatic hypotension characterized by dizziness when rising to stand. The nurse should follow up, but this is not the priority. (Option D) Metformin is a biguanide oral antidiabetic medication used to treat type 2 diabetes mellitus. Lovastatin is a statin medication used to treat hyperlipidemia. A common side effect of metformin is stomach upset. The nurse should assess the client's symptoms, but this is not the priority. Educational objective: Monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil) are prescribed for the management of depression. A client who reports headache and has taken an MAOI and a nasal decongestant (eg, pseudoephedrine) should be evaluated immediately for hypertensive crisis.

The Nurse Receives Handoff Report on 4 Clients