A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Rationale:

A. Encourage the child to take naps during the day: While rest is important during flares, excessive daytime napping can contribute to stiffness and reduced physical function. Regular activity is encouraged to maintain joint mobility and overall well-being.

B. Apply splints to the child's extremities during the day: Splints may be used during sleep or periods of rest to reduce deformities, but wearing them during the day can interfere with play, physical therapy, and functional use of joints, which are important in school-age children.

C. Have the child take a tub bath each morning: Warm baths help relieve joint stiffness and pain, especially after nighttime immobility. Morning baths can promote flexibility, ease discomfort, and prepare the child for physical activity during the day.

D. Keep the child on bedrest as long as pain persists: Prolonged bedrest may worsen joint stiffness and muscle atrophy. Controlled physical activity is beneficial and helps prevent complications related to immobility. Pain management should support continued movement.

Rationale for Correct Choices:

• Blurred vision: Amitriptyline causes anticholinergic effects such as blurred vision by impairing lens accommodation. This effect is common in the early stages of treatment and may improve over time.
• Orthostatic hypotension: Amitriptyline reduces peripheral vascular resistance, which can cause blood pressure to drop when a client changes position. This increases the risk for falls, especially in older adults.
• Urinary retention: Anticholinergic effects from amitriptyline reduce bladder contractility, leading to urinary retention. This is especially concerning in clients with prostate enlargement or existing urinary difficulties.
• Constipation: Decreased gastrointestinal motility caused by anticholinergic activity makes constipation a common and expected side effect. Clients should be advised to increase fiber and fluid intake.

Rationale for Incorrect Choices:

• HEENT: Hearing loss is not associated with tricyclic antidepressants like amitriptyline, which do not affect the auditory system. Photophobia typically results from conditions like migraines or uveitis, not from tricyclic antidepressant use.
• Cardiovascular: Hypertension is not a known side effect of amitriptyline. The medication more commonly lowers blood pressure through vasodilation. Bradycardia is not expected with amitriptyline. In fact, the drug may cause tachycardia due to its effect on cardiac conduction.
• Genitourinary: Urinary incontinence is not typical with amitriptyline. The drug’s anticholinergic properties reduce bladder contractility, increasing the risk of retention instead. Increased libido is not a side effect of tricyclic antidepressants. These medications are more likely to decrease libido and may contribute to sexual dysfunction.
• Gastrointestinal: Dry mouth is a common anticholinergic effect but does not directly impact gastrointestinal motility, making it a less appropriate answer in this system category. Diarrhea is not expected with anticholinergic drugs like amitriptyline, which slow bowel movements and increase the risk for constipation.