The client has been diagnosed with severe depression and prescribed sertraline (Zoloft). Which assessment of the client by the nurse is a priority after initiation of the medication?

Choice A reason: Setting limits on aggressive behavior during mania ensures safety by addressing the immediate threat. Mania involves elevated mood and impulsivity, which can lead to harmful actions. Clear boundaries reduce escalation, protect others, and help de-escalate the client’s heightened state without immediate medication or isolation.

Choice B reason: Offering a group on coping skills is inappropriate during acute mania with threatening behavior, as the client’s impulsivity and agitation impair their ability to engage in group therapy. Safety and de-escalation are priorities before addressing long-term coping strategies.

Choice C reason: Administering PRN medications, such as antipsychotics or benzodiazepines, may help calm mania but is not the initial action. Setting limits addresses immediate safety concerns first, allowing for safer medication administration if needed, as medications take time to act.

Choice D reason: Insisting on a “time-out” may escalate agitation in a manic client, as isolation can increase feelings of persecution or agitation. This approach is less effective than setting clear, calm limits to de-escalate threatening behavior and ensure unit safety.

Choice A reason: Nausea and vomiting can occur in cardiac conditions due to reduced perfusion to the gastrointestinal system. However, in atrial fibrillation with a rapid ventricular rate, the priority is assessing for symptoms of reduced cardiac output, such as hypotension and dizziness, which are more immediate and life-threatening.

Choice B reason: Hypertension and headache are not typical of rapid atrial fibrillation, which usually causes reduced cardiac output due to ineffective atrial contractions. These symptoms are more associated with hypertensive crises or other conditions, making them less relevant for this dysrhythmia.

Choice C reason: Flattened neck veins suggest hypovolemia or low venous pressure, not typical in acute atrial fibrillation, where jugular vein distension may occur due to heart failure. Hypotension and dizziness are more direct indicators of compromised cardiac output in this scenario.

Choice D reason: Rapid atrial fibrillation impairs atrial filling, reducing cardiac output and causing hypotension. Dizziness results from decreased cerebral perfusion due to low blood pressure. These are critical symptoms to assess, as they indicate hemodynamic instability, requiring immediate intervention to prevent further complications.