What should a nurse do first when a client on phenelzine reports a throbbing headache?

In the context of a client taking phenelzine and reporting a throbbing headache, the first action of obtaining the client's vital signs is crucial. Phenelzine is a monoamine oxidase inhibitor (MAOI) used primarily for treating depression, and it can have significant interactions with certain foods and medications. A throbbing headache could indicate a hypertensive crisis, especially if there has been a dietary indiscretion involving tyramine-rich foods, which can precipitate this serious condition.

By assessing the client's vital signs initially, particularly blood pressure, the nurse can determine whether there are any alarming changes that could require immediate intervention, such as a hypertensive emergency. It's essential to gather this information before considering any other interventions, such as administering medications or contacting the healthcare provider, as the vital signs can guide the appropriate next steps in management. This assessment ensures that the nursing actions taken are based on objective clinical data, promoting patient safety and effective care.