A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?

Choice A reason:

Increased urinary frequency Increased urinary frequency is not a typical adverse effect of sertraline. However, some individuals may experience changes in urinary habits due to various factors, but it is not directly related to sertraline use.

Choice B reason

Dry cough Dry cough is not a commonly reported adverse effect of sertraline. Cough is not a typical symptom associated with this medication.

Choice C reason

Metallic taste in the mouth While some individuals may experience changes in taste as a side effect of sertraline, a metallic taste in the mouth is not one of the commonly reported adverse effects. Taste changes are usually mild and temporary.

Choice D reason

Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used to treat conditions like depression, anxiety disorders, and obsessive-compulsive disorder. While most individuals tolerate sertraline well, it can cause certain adverse effects, and excessive sweating (also known as diaphoresis) is one of them.

Excessive sweating is a common side effect of sertraline and other SSRIs. It can manifest as increased sweating during the day or night, even in cooler environments. The degree of sweating can vary among individuals, and some may experience it more than others.

The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.