Patient Data

Exhibits

The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech.

Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of

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as evidenced by

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.

Rationale:

• Assess for pattern of bowel movements: Sertraline, a SSRI, commonly causes gastrointestinal side effects, including diarrhea or constipation. Monitoring the client's bowel movement pattern is essential to detect and manage these potential adverse effects.
• Monitor suicidal ideation: Clients with PTSD and major depressive symptoms, especially those recently expressing suicidal intent, require close monitoring for suicidality when initiating SSRIs like sertraline, as energy to act on suicidal thoughts may increase before mood improves.
• Weigh client weekly: SSRIs, including sertraline, can lead to weight changes. Regular weight monitoring helps detect significant weight gain or loss, especially in clients with changes in appetite or nutrition due to mood disorders.

• Offer frequent sips of fluids: There is no current evidence of dehydration or dry mouth. SSRIs like sertraline do not routinely require fluid intake encouragement unless side effects or clinical symptoms indicate a need.
• Watch for hypotension: Sertraline is not commonly associated with hypotension. Orthostatic hypotension is more typical with tricyclic antidepressants or antipsychotics, not SSRIs.

Rationale:
A. Encouraging the client to join a support group: While beneficial, referring the client to a support group does not immediately address the client's psychosocial need for acceptance in the nurse-client interaction. Acceptance should first be modeled directly by caregivers.

B. Allowing the client to ventilate feelings: This addresses emotional support but does not necessarily promote acceptance. The client may still feel socially isolated or judged if the nurse maintains physical distance or acts hesitantly.

C. Shaking the client's hand during an introduction: This action demonstrates respect, inclusion, and nonjudgmental care. It helps normalize the interaction and signals to the client that the nurse does not view their skin condition as repulsive or infectious. Such gestures reduce stigma and build trust.

D. Wearing gloves when interviewing the client: Gloving when unnecessary can send a message that the client is contaminated. For non-contact interviews, gloves are not required and may make the client feel rejected or judged. It contradicts acceptance goals.