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A nurse is caring for a client in a clinic.

Exhibits

For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Body System

Common Adverse Effects

Head, eyes, ears, nose, and throat (HEENT)

dropdown

Cardiovascular

dropdown

Genitourinary

dropdown

Gastrointestinal

dropdown

Note: Each drop down must have 1 response selected.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B","dropdown-group-3":"A","dropdown-group-4":"C"}

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. The client slept 5 hr the previous night: Acute manic episodes often involve severe sleep deprivation, sometimes going days without sleep. Achieving 5 hours of rest indicates reduced hyperactivity and a positive response to treatment.
B. The client takes 2 short naps during the day: While napping may seem beneficial, in manic clients it can indicate ongoing disrupted sleep-wake cycles. Full, restorative nighttime sleep is a more reliable sign of improvement.
C. The client consumes 8 oz of high-calorie fluids each hour: During mania, clients often neglect nutritional needs. Actively consuming adequate fluids suggests improved awareness, cooperation, and decreased impulsivity.
D. The client engages in quiet activities in their room: Initially, the client was extremely restless and disruptive. Choosing calm, solitary activities reflects improved impulse control and reduced manic energy.
E. The client appears to listen to unseen others: This suggests persistent auditory hallucinations, indicating that psychotic symptoms remain present and untreated or only partially managed. This is not a sign of improvement.

A. Beneficence B. Fidelity C. Veracity D. Autonomy

Correct Answer is A

Explanation

A. Beneficence: Sitting with the client to provide comfort demonstrates beneficence, which involves actions that promote the well-being and best interests of the client, including offering emotional support during difficult times.
B. Fidelity: Fidelity refers to the nurse’s obligation to be faithful and keep promises made to the client, which involves trustworthiness but does not specifically address providing comfort through presence.
C. Veracity: Veracity is the ethical principle of truth-telling and honesty. Providing comfort by sitting with the client is supportive but not directly related to truthfulness.
D. Autonomy: Autonomy concerns respecting the client’s right to make independent decisions about their care. Offering comfort by presence supports emotional needs but does not directly involve respecting autonomy.

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Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?

Correct Answer is A

Explanation

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