A nurse is educating a client who wants to use St. John's wort as an alternative treatment for depression. The nurse should inform the client that St. John's wort may interact with which of the following conventional drugs?

The correct answer is D. All of the above.

Choice A reason: This statement is correct and the nurse should ask the client about headache as a possible adverse effect that may occur after chiropractic manipulation. Chiropractic manipulation is a manual therapy that involves applying controlled, sudden force to specific joints of the spine or other parts of the body to improve mobility and function. However, it may also cause some mild and transient side effects, such as headache, in 33-60% of patients. The mechanism of headache after chiropractic manipulation is not fully understood, but it may be related to changes in blood flow, muscle tension, or nerve irritation in the cervical region. Therefore, the nurse should assess the client for headache, its severity, duration, location, and associated symptoms, and advise the client to report any persistent or severe headache to his or her health care provider.

Choice B reason: This statement is also correct and the nurse should ask the client about dizziness as a possible adverse effect that may occur after chiropractic manipulation. Dizziness is a common side effect of chiropractic manipulation, especially of the cervical spine. It may manifest as vertigo (a sensation of spinning or moving), disequilibrium (a sensation of imbalance or unsteadiness), or presyncope (a sensation of faintness or lightheadedness). The mechanism of dizziness after chiropractic manipulation is not fully understood, but it may be related to changes in blood pressure, vestibular function, or proprioception in the cervical region. Therefore, the nurse should assess the client for dizziness, its type, severity, duration, triggers, and associated symptoms, and advise the client to report any persistent or severe dizziness to his or her health care provider.

Choice C reason: This statement is also correct and the nurse should ask the client about nausea as a possible adverse effect that may occur after chiropractic manipulation. Nausea is a less common but possible side effect of chiropractic manipulation. It may be related to dizziness, anxiety, or visceral stimulation caused by spinal manipulation. Therefore, the nurse should assess the client for nausea, its severity, frequency, triggers, and associated symptoms, and advise the client to report any persistent or severe nausea to his or her healthcare provider.

Choice D reason: This statement is correct because it includes all of the above statements. Chiropractic manipulation may cause various mild and transient side effects in some patients. Some of these side effects may include headache, dizziness, and nausea. Therefore, choice D is the best answer for asking the client about possible adverse effects that may occur after chiropractic manipulation.

The correct answer is

D. All of the above.

Choice A reason: This statement is correct and the nurse should inform the client that St. John's wort may interact with oral contraceptives. St. John's wort is an herbal supplement that has antidepressant and anti-inflammatory effects. However, it may also affect the metabolism and clearance of some drugs by inducing the activity of certain enzymes in the liver. One of these enzymes, called CYP3A4, is responsible for breaking down oral contraceptives, such as ethinyl estradiol and norethindrone. Taking St. John's wort with oral contraceptives may reduce their effectiveness and increase the risk of pregnancy or breakthrough bleeding. Therefore, the nurse should advise the client to use an alternative or additional method of birth control while taking St. John's wort.

Choice B reason: This statement is also correct and the nurse should inform the client that St. John's wort may interact with anticoagulants. Anticoagulants are drugs that prevent blood clots by inhibiting the activity of certain clotting factors in the blood. Some examples of anticoagulants are warfarin, heparin, and dabigatran. Taking St. John's wort with anticoagulants may decrease their effectiveness and increase the risk of thrombosis or embolism. This is because St. John's wort may induce the activity of CYP3A4 and CYP2C9, two enzymes that are involved in the metabolism and clearance of warfarin and dabigatran. Therefore, the nurse should advise the client to monitor his or her blood clotting tests, such as INR or PT, and to report any signs or symptoms of bleeding or clotting while taking St. John's wort.

Choice C reason: This statement is also correct and the nurse should inform the client that St. John's wort may interact with antiretrovirals. Antiretrovirals are drugs that inhibit the replication of human immunodeficiency virus (HIV) by targeting different stages of its life cycle. Some examples of antiretrovirals are protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and integrase inhibitors. Taking St. John's wort with antiretrovirals may decrease their effectiveness and increase the risk of HIV resistance or progression to acquired immunodeficiency syndrome (AIDS). This is because St. John's wort may induce the activity of CYP3A4 and P-glycoprotein, two proteins that are involved in the absorption, distribution, metabolism, and excretion of many antiretrovirals. Therefore, the nurse should advise the client to avoid taking St. John's wort with antiretrovirals and to consult his or her health care provider before starting or stopping any herbal supplements.

Choice D reason: This statement is correct because it includes all of the above statements. St. John's wort may interact with many conventional drugs by affecting their pharmacokinetics or pharmacodynamics. Some of these interactions may have serious consequences for the client's health and well-being. Therefore, choice D is the best answer for informing the client that St. John's wort may interact with oral contraceptives, anticoagulants, and antiretrovirals.