A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?

Explanation

C. Epistaxis

Heparin is an anticoagulant medication used to prevent blood clot formation. One of the potential adverse effects of heparin therapy is bleeding. Epistaxis, or nosebleeds, can be a sign of abnormal bleeding and should be reported to the provider for further evaluation and adjustment of the treatment plan if necessary.

Weight gain in (option A) is not a common adverse effect of heparin. Weight gain can be caused by various factors, but it is not directly related to heparin administration.

Bradycardia (slow heart rate) in (option B) is not a common adverse effect of heparin. Bradycardia can be caused by other factors unrelated to heparin therapy and should be evaluated separately.

Anorexia (loss of appetite) in (option D) is not typically associated with heparin therapy. Anorexia can have various causes, but it is not directly linked to heparin administration.

Therefore, the nurse should report the occurrence of epistaxis (option C) to the healthcare provider as a potential adverse effect of heparin therapy in the client.

The AIMS is specifically designed to assess for the presence and severity of abnormal involuntary movements, which can be a side effect of long-term antipsychotic medication use, including tardive dyskinesia. It consists of a series of standardized movements and observations that assess different body regions for abnormal movements. The nurse can use this tool to monitor the client's movements and identify any signs of tardive dyskinesia.

Mental Status Examination (MSE): The MSE is a comprehensive assessment of a client's mental status, including their cognition, mood, and thought processes. While the MSE is an important tool in assessing overall mental health, it is not specific to tardive dyskinesia. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a screening tool for depression that assesses the severity of depressive symptoms. While depression can be a comorbidity in individuals with schizophrenia, the PHQ-9 does not directly assess for tardive dyskinesia. Brief Psychiatric Rating Scale (BPRS): The BPRS is a rating scale used to assess the severity of psychiatric symptoms in individuals with mental disorders. While it is useful in evaluating overall symptomatology in schizophrenia, it does not specifically target tardive dyskinesia.