A nurse is caring for a client who is taking a tricyclic antidepressant. For which of the following findings should the nurse monitor as an adverse effect of tricyclic antidepressants?

Orthostatic hypotension

Diarrhea

Hyperactivity

increased urinary output

Answer and Explanation

The Correct Answer is A

A. Orthostatic hypotension: Orthostatic hypotension, a sudden drop in blood pressure upon standing up, is a common adverse effect of tricyclic antidepressants. TCAs can block the alpha-1 adrenergic receptors, leading to decreased vascular tone and subsequent orthostatic hypotension.

B. Diarrhea: Diarrhea is not typically associated with tricyclic antidepressants. In fact, constipation is a more common gastrointestinal adverse effect of TCAs due to their anticholinergic properties, which can slow down bowel motility.

C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.

D. Increased urinary output: Tricyclic antidepressants can cause urinary retention rather than increased urinary output. Anticholinergic effects of TCAs can lead to urinary hesitancy, difficulty initiating urination, or retention, particularly in individuals with benign prostatic hyperplasia.

C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.

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Correct Answer is B

Explanation

A. Keep the client hospitalized until there is no longer a threat

Nurses do not have the authority to unilaterally detain clients in a hospital. This decision is typically made by a physician or a legal authority, especially in the context of a medical-surgical unit where mental health professionals may need to be involved.Keeping a client hospitalized without proper legal procedures and mental health evaluation could lead to legal repercussions for unlawful detainment.

B. Ensure the client's ex-partner is notified of the threat

This option involves notifying the potential victim about the threat made by the client. While it's important to ensure the safety of others, the nurse's legal duty primarily lies with protecting the confidentiality of the client's information. Without consent from the client or a legal obligation, such as mandatory reporting laws for imminent harm, the nurse cannot disclose the threat to the ex-partner.

C. Ask a friend or family member to monitor the client

While involving family or friends might provide support, it is not a sufficient or appropriate response to a threat of harm. It does not address the immediate risk posed to the ex-partner and may not comply with legal obligations.

D. Transfer the client to a mental health facility

Transferring the client to a mental health facility for further evaluation and treatment might be necessary, but it must be done through appropriate medical and legal channels. It addresses the need for a thorough mental health assessment and ensures that the client receives the necessary care.

A. Use detailed explanations when providing education to the client B. Maintain a stimulating environment for the client C. Provide the cant with a structured schedule of daily activities D. Limit time for rituals to 20 min each day

Correct Answer is C

Explanation

A. Use detailed explanations when providing education to the client: Providing detailed explanations can help the client better understand their condition and treatment, which is essential for managing obsessive-compulsive disorder (OCD). This intervention promotes client education and empowerment, enabling them to participate more effectively in their care and treatment.

B. Maintain a stimulating environment for the client: Individuals with OCD often benefit from a calm and organized environment rather than a stimulating one. A stimulating environment might exacerbate anxiety and OCD symptoms. Therefore, maintaining a calm and structured environment is typically more beneficial for clients with OCD.

C. Provide the client with a structured schedule of daily activities: Providing a structured schedule of daily activities can help regulate the client's routine and provide a sense of predictability, which can be comforting for individuals with OCD. A structured schedule can also help minimize the impact of OCD symptoms on daily functioning by providing a framework for completing tasks and managing time effectively.

D. Limit time for rituals to 20 minutes each day: Limiting time for rituals to a specific duration each day may not be appropriate or effective for all clients with OCD. While gradual exposure and response prevention (ERP) therapy may involve gradually reducing the time spent on rituals, setting a specific time limit may not address the underlying causes of OCD and could potentially increase anxiety and distress for the client.

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A nurse is caring for a client who is taking a tricyclic antidepressant. For which of the following findings should the nurse monitor as an adverse effect of tricyclic antidepressants?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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