A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?

Rationale:

• HEENT – Dry mouth: SSRIs such as sertraline commonly cause dry mouth due to anticholinergic effects and altered salivary secretion. Clients may notice difficulty swallowing, increased thirst, or altered taste. Education should include strategies to manage dry mouth, such as frequent sips of water, sugar-free gum, or saliva substitutes.

• Cardiovascular – Tachycardia: Sertraline may increase sympathetic nervous system activity, leading to mild tachycardia. Clients should monitor heart rate and report palpitations, lightheadedness, or other cardiovascular changes. Although usually mild, monitoring is important for those with underlying heart conditions.

• Genitourinary – Urinary retention: SSRIs can interfere with detrusor muscle function and bladder emptying, leading to urinary retention in some clients. Teaching includes observing for difficulty urinating, straining, or reduced urine output, and reporting persistent problems to the provider.

• Gastrointestinal – Diarrhea: Gastrointestinal upset is common when starting SSRIs, including diarrhea, nausea, and abdominal cramping. This occurs due to increased serotonin in the gut. Patients should be advised to maintain hydration and report severe or persistent symptoms.

A. "Purchase a gift to give to your son from your baby.": Giving a gift from the new baby helps the older child feel included and valued, reducing feelings of jealousy or displacement. This approach supports positive sibling bonding and eases the transition to the new family dynamic.

B. "Surprise your son with a new bedroom after you bring the baby home.": Major changes like moving the child to a new bedroom should be introduced gradually before the baby’s arrival. Sudden changes can increase anxiety and feelings of insecurity during an already stressful transition.

C. "Make sure you are holding your baby when your son comes to visit you in the hospital.": This may inadvertently foster jealousy or feelings of neglect in the older child. Allowing the child to participate in care or spend time with the baby under supervision is more supportive of adjustment.

D. "Use medical terminology when teaching your son about your new baby.": Preschool-aged children benefit from simple, age-appropriate language. Medical terminology can confuse or overwhelm a 4-year-old, making the learning less effective and increasing anxiety.