A nurse in an outpatient mental health center is caring for a client.

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with paranoid personality disorder or borderline personality disorder. Each finding may support more than 1 personality disorder or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Rationale:

A. Fibrinogen level: Fibrinogen is a clotting factor that can reflect coagulation activity, but it is not used to monitor warfarin therapy. It is more relevant in conditions like DIC or liver disease, not for warfarin dose adjustments.

B. aPTT: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy. Warfarin, which affects the extrinsic pathway of coagulation, does not significantly impact aPTT levels.

C. INR: The international normalized ratio (INR) is the standard test used to monitor warfarin therapy. It reflects the effect of warfarin on prothrombin time and guides safe and effective dosing to maintain therapeutic anticoagulation.

D. Platelet count: While platelet count helps evaluate bleeding risk and detect thrombocytopenia, it is not used to guide warfarin dosing. Warfarin works by inhibiting vitamin K–dependent clotting factors, not by affecting platelet production.

Rationale for correct choices:

• A change in mood: Mood changes, including depression, irritability, or suicidal thoughts, are serious adverse effects associated with isotretinoin use. Adolescents are particularly vulnerable to these side effects, and any mood alterations during treatment warrant immediate provider notification.
• Decreased night vision: Isotretinoin can lead to visual disturbances, including decreased night vision, which may be sudden and irreversible. This adverse effect is rare but serious, and any signs of visual impairment should be reported promptly to prevent injury or permanent damage.

Rationale for incorrect choices:

• The development of dry eyes: Dry eyes are a common and expected side effect of isotretinoin, often due to mucous membrane dryness. While uncomfortable, it is not typically dangerous and can usually be managed with lubricating eye drops or supportive care without immediate provider contact.
• Dry mouth: Dry mouth occurs frequently with isotretinoin due to its drying effects on mucosal surfaces. It is bothersome but not dangerous, and clients can manage it with increased fluid intake and sugar-free lozenges. It doesn’t require urgent medical attention unless severe.
• Nausea: Nausea is not a common or concerning side effect of isotretinoin. If persistent or severe, it may require evaluation, but it is not a priority symptom for immediate provider contact unless accompanied by other warning signs like abdominal pain or jaundice.
• Sunburn: Increased photosensitivity is an expected effect of isotretinoin, and clients should be advised to wear sunscreen and protective clothing. Sunburn, while uncomfortable, is not an emergency and does not require immediate medical consultation unless it becomes severe.
• Worsening of acne: An initial acne flare is a known and expected part of isotretinoin therapy as pores begin to purge. This typically improves after several weeks and does not indicate treatment failure or require immediate provider notification unless accompanied by signs of infection.
• Engagement in sexual activity: While not a symptom, sexual activity is significant for female clients due to isotretinoin's teratogenicity. However, since this client has a negative hCG and is not sexually active, this is part of routine risk counselling not an immediate concern unless pregnancy is possible.