Patient Data

 

Exhibits

The nurse is linking the client's symptoms to the most likely pharmacologic treatment.

Choose the most likely option for the information missing from the statement by selecting from the list of options provided.

The most appropriate medication class to treat the client's presentation is a

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A. Calculate the intake and output: Measuring intake and output directly reflects fluid balance, making it one of the most reliable ways to determine if fluid restriction and diuretics are effective. Tracking fluid intake compared to urine output helps assess reduction in fluid overload.

B. Assess pulse rate: While monitoring pulse rate is part of routine assessment, it does not provide a clear picture of whether fluid overload is improving. Changes in pulse may occur with dehydration, arrhythmias, or other conditions, but it is not a primary measure of fluid balance.

C. Monitor the temperature: Body temperature is important for identifying infection or inflammation but does not indicate fluid status. Monitoring temperature would not help evaluate whether fluid restriction and diuretic therapy are relieving fluid overload.

D. Checking for orthostatic hypotension: Orthostatic changes can suggest hypovolemia or dehydration but are less useful for measuring the gradual effectiveness of fluid restriction. They may be monitored if over-diuresis is suspected, but they are not the best evaluation tool.

E. Obtain a daily weight: Daily weight is one of the most accurate indicators of fluid balance. A decrease in weight reflects effective removal of excess fluid, as even small weight changes can indicate significant fluid gain or loss in the body.

A. Tell the client that the medication's side effects will most likely dissipate over time: While side effects may lessen with continued use, this response does not address the client’s intent to stop the medication safely.

B. Inform the client that gradual tapering must be used to discontinue the medication: Abrupt discontinuation of antidepressants can lead to withdrawal symptoms and risk of relapse. Educating the client about the need for a gradual taper ensures safe discontinuation and continuity of care.

C. Remind the client that feeling better is the therapeutic effect of the medication: Acknowledging the therapeutic benefit is important but does not provide guidance on safely stopping the medication or addressing the client’s concerns.

D. Tell the client to discuss the medication side effects with the healthcare provider (HCP): Encouraging communication with the HCP is appropriate, but the immediate priority is to inform the client that discontinuation must be gradual to prevent adverse effects.