A nurse is assessing a client who is taking an osmotic laxative.
Which of the following findings should the nurse identify as an indication of fluid volume deficit?

a.While weight changes can be concerning, they are not typically life-threatening and can occur as a common side effect of antidepressants, including citalopram. Monitoring is important, but it does not require immediate reporting.

b.This is the priority to report because confusion can indicate a serious reaction to the medication, such as serotonin syndrome, especially if it occurs in conjunction with other symptoms like agitation, hallucinations, or rapid heart rate. Confusion can also signal worsening mental status, which is critical for someone with major depression.

c.This refers to teeth grinding, which can occur with certain antidepressants. While it should be monitored and possibly addressed with interventions, it is generally not an immediate concern compared to confusion.

d.Sleep disturbances can be a side effect of citalopram and may need adjustment of treatment or recommendations for sleep hygiene, but they are not as urgent as confusion.

The nurse who caused the error is responsible for completing an incident report. An incident report is a tool for documenting any event that deviates from the standard of care or causes harm to a client, staff member, or visitor. The purpose of an incident report is to improve quality and safety, not to assign blame or punish anyone. The nurse who caused the error should fill out the report as soon as possible after the event, providing factual and objective information.

A. The quality improvement committee is not directly involved in the incident and does not complete the report. The committee may review the report later to identify trends and areas for improvement.

B. The charge nurse is not responsible for completing the report, although they may assist or supervise the nurse who caused the error.The charge nurse may also notify the provider and other relevant staff members about the incident.

C.The nurse who caused the error may be involved in providing details and information about the incident, but the nurse who discovers the error is the one responsible for completing the incident report to ensure that all relevant information is accurately documented.

D. It is crucial for the nurse who discovers the error to complete the incident report to ensure that all relevant details are accurately documented. This allows for a thorough investigation and implementation of corrective actions to prevent future errors.