A client who is prescribed a tricyclic antidepressant is brought to the emergency department with a suspected overdose. Which would the nurse assess to support this suspicion? Select all that apply.

blurred vision

urinary retention

diarrhea

headache

pale, moist skin

Answer and Explanation

Correct Answer : A,B

A. blurred vision: Blurred vision is a common side effect of tricyclic antidepressants due to their anticholinergic effects, and it can be a sign of overdose.

B. urinary retention: Urinary retention is another anticholinergic side effect of tricyclic antidepressants and can indicate an overdose.

C. diarrhea: Diarrhea is not typically associated with tricyclic antidepressant overdose. Anticholinergic effects generally lead to constipation, not diarrhea.

D. headache: While a headache can occur in many situations, it is not a specific indicator of tricyclic antidepressant overdose.

E. pale, moist skin: Pale, moist skin is not a typical symptom of tricyclic antidepressant overdose. Overdose symptoms more commonly include dry skin due to anticholinergic effects.

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Correct Answer is C

Explanation

A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).

B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.

C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.

D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.

A. Ensure that there is a complete and functional suction system at the bedside. B. Position the head of the client's bed at a height of 30° to 45°. C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. D. Encourage the client to hold her breath while she is attempting to swallow.

Correct Answer is A

Explanation

A. Ensure that there is a complete and functional suction system at the bedside. This is an essential precaution for clients with dysphagia because they are at high risk of aspiration. Having suction equipment ready allows for quick intervention if the client begins to choke or aspirate.

B. Position the head of the client's bed at a height of 30° to 45°. This positioning is too low for feeding. To reduce the risk of aspiration, the head of the bed should be elevated to at least 45° to 90° during feeding. Therefore, this option is less safe.

C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. Smaller, more frequent meals are generally recommended to prevent fatigue and reduce the risk of aspiration, as larger meals can be overwhelming and increase the risk of choking.

D. Encourage the client to hold her breath while she is attempting to swallow. This is not a standard or safe practice for managing dysphagia. Safe swallowing techniques typically include ensuring the client is alert, properly positioned, and eating slowly with small bites.

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A client who is prescribed a tricyclic antidepressant is brought to the emergency department with a suspected overdose. Which would the nurse assess to support this suspicion? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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