A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

• HEENT – Dry mouth; Amitriptyline has strong anticholinergic effects, which inhibit salivary gland secretion, commonly resulting in dry mouth. This side effect can affect oral comfort, dental health, and appetite.
• Cardiovascular – Tachycardia: Tricyclic antidepressants like amitriptyline can cause tachycardia due to their anticholinergic properties and direct effects on cardiac conduction. These drugs inhibit vagal tone, which increases heart rate, and can also affect the sodium channels in cardiac tissue.
• Genitourinary – Urinary retention: Amitriptyline’s anticholinergic activity relaxes the detrusor muscle and contracts the internal urethral sphincter, impairing normal bladder emptying. This can lead to difficulty initiating urination and incomplete bladder emptying, particularly in older adults.
• Gastrointestinal – Constipation: By inhibiting parasympathetic activity in the GI tract, amitriptyline slows peristalsis, leading to constipation. This side effect is common and can become severe without dietary adjustments or the use of stool softeners.

A. Inform the client that they cannot refuse medical examination: All patients, including those who have been sexually assaulted, have the legal right to refuse any part of the examination. Informed consent is essential.
B. Report laboratory findings to law enforcement: Unless there is a mandatory reporting law in effect for that specific jurisdiction, results and disclosures require the client's consent before being shared with law enforcement.
C. Prepare to administer prophylaxis for STIs: Clients who have experienced sexual assault are at risk for sexually transmitted infections. Early administration of prophylactic antibiotics is a standard, time-sensitive intervention.
D. Assess for thoughts of self-harm: Sexual assault survivors are at increased risk for depression, suicidal ideation, and PTSD. A mental health assessment should be conducted immediately to ensure safety.
E. Recommend emergency contraception to the client: If pregnancy is a potential concern, emergency contraception should be offered within a limited time window after the assault, regardless of the client’s current hCG level.