A nurse in a community clinic is caring for a client who requests assistance with smoking cessation. The nurse should expect a prescription for which of the following medications?

Rationale for correct choices:

• Blood pressure: A reading of 148/94 mm Hg is elevated and meets criteria for gestational hypertension, especially in a client who is gravida 1 para 0. It raises concern for preeclampsia and must be closely monitored, particularly with concurrent symptoms like headache and edema.
• DTR: A deep tendon reflex of 3+ is considered hyperreflexic and may signal increased central nervous system irritability. In the setting of elevated blood pressure and other preeclampsia signs, it raises concern for worsening severity or impending seizure activity.
• Lower extremity assessment: The presence of 1+ dependent edema can be a normal pregnancy finding, but when paired with facial swelling, recent weight gain, and elevated blood pressure, it becomes significant and suggests fluid retention associated with preeclampsia.
• Weight assessment: A gain of 0.68 kg (1.5 lb) in a week may seem modest, but when it is sudden and combined with facial and dependent edema, it can indicate abnormal fluid accumulation. This pattern is concerning for preeclampsia and requires follow-up.
• Nausea: While nausea is common in pregnancy, its presence along with right upper quadrant pain and headache raises red flags for severe preeclampsia or HELLP syndrome. These are warning signs of potential hepatic involvement or worsening disease.

Rationale for incorrect choices:

• Fundal height: A fundal height of 29 cm is consistent with gestational age around 29 weeks and does not indicate an abnormal finding in this context. No follow-up is needed unless measurements are inconsistent with gestational dating.
• Respiratory assessment: The client’s lungs are clear to auscultation and respirations are even and non-labored. Oxygen saturation is 95% on room air, which is within normal range during pregnancy, so no respiratory issues require intervention.
• Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 beats per minute. There are no reported decelerations or signs of distress, so no immediate follow-up is indicated for the fetal tracing.

Rationale for Correct Choices:

• Blurred vision: Amitriptyline causes anticholinergic effects such as blurred vision by impairing lens accommodation. This effect is common in the early stages of treatment and may improve over time.
• Orthostatic hypotension: Amitriptyline reduces peripheral vascular resistance, which can cause blood pressure to drop when a client changes position. This increases the risk for falls, especially in older adults.
• Urinary retention: Anticholinergic effects from amitriptyline reduce bladder contractility, leading to urinary retention. This is especially concerning in clients with prostate enlargement or existing urinary difficulties.
• Constipation: Decreased gastrointestinal motility caused by anticholinergic activity makes constipation a common and expected side effect. Clients should be advised to increase fiber and fluid intake.

Rationale for Incorrect Choices:

• HEENT: Hearing loss is not associated with tricyclic antidepressants like amitriptyline, which do not affect the auditory system. Photophobia typically results from conditions like migraines or uveitis, not from tricyclic antidepressant use.
• Cardiovascular: Hypertension is not a known side effect of amitriptyline. The medication more commonly lowers blood pressure through vasodilation. Bradycardia is not expected with amitriptyline. In fact, the drug may cause tachycardia due to its effect on cardiac conduction.
• Genitourinary: Urinary incontinence is not typical with amitriptyline. The drug’s anticholinergic properties reduce bladder contractility, increasing the risk of retention instead. Increased libido is not a side effect of tricyclic antidepressants. These medications are more likely to decrease libido and may contribute to sexual dysfunction.
• Gastrointestinal: Dry mouth is a common anticholinergic effect but does not directly impact gastrointestinal motility, making it a less appropriate answer in this system category. Diarrhea is not expected with anticholinergic drugs like amitriptyline, which slow bowel movements and increase the risk for constipation.