A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects?

Rationale for correct choices:
• a change in mood: Isotretinoin has been associated with psychiatric effects including depression, mood swings, aggression, and suicidal ideation, particularly in adolescents. Any noticeable mood or behavioral changes require immediate provider notification so the medication can be reassessed and mental health support initiated if needed.

• decreased night vision: Isotretinoin can impair dark adaptation and cause decreased night vision due to its effects on the retina. This adverse effect may be sudden or irreversible, making early reporting essential to prevent safety risks such as accidents while driving in low-light conditions.

Rationale for incorrect choices:
• nausea: Mild gastrointestinal upset can occur with isotretinoin and is generally expected rather than emergent. This symptom is usually managed with supportive measures and does not require immediate discontinuation unless severe or persistent.

• dry mouth: Mucocutaneous dryness, including dry lips and mouth, is a very common and expected side effect of isotretinoin. This is typically managed with hydration and emollients and does not warrant urgent provider notification.

• the development of dry eyes: Dry eyes are a common isotretinoin effect related to decreased sebaceous gland activity. While uncomfortable and relevant to report at routine follow-up, it is not an urgent finding unless severe or affecting vision.

• sunburn: Photosensitivity can occur during isotretinoin therapy, making sunburn more likely. This is addressed with sun protection education and does not indicate a serious adverse reaction requiring immediate notification.

• engagement in sexual activity: Sexual activity itself is not an adverse effect of isotretinoin. Although pregnancy prevention is critical due to teratogenicity, sexual activity alone does not represent a medication-related complication.

• worsening of acne: Acne may initially worsen during early isotretinoin therapy as part of the treatment response. This is a known and expected effect and does not require urgent provider contact unless severe or accompanied by systemic symptoms.

A. Witnessing the death of their parents and sibling: Experiencing such severe trauma places the client at high risk for post-traumatic stress disorder (PTSD) and complicated grief. Immediate follow-up is necessary to assess emotional safety and provide appropriate mental health interventions.

B. Attends school regularly: Regular school attendance is a positive sign of functioning and does not require immediate follow-up. It indicates that the client maintains some level of daily routine and social engagement.

C. Client experiences nightmares: Nightmares following trauma can indicate PTSD or acute stress reaction. These symptoms warrant prompt assessment and intervention to prevent worsening sleep disturbances, anxiety, or functional impairment.

D. Blood pressure 122/80 mm Hg: This is within normal limits for a 16-year-old and does not require immediate follow-up. It is not indicative of acute physical risk.

E. Heart rate 99/min: While slightly elevated, this heart rate is within a mild range of normal for adolescents under stress and does not require immediate follow-up unless accompanied by other acute symptoms.

F. Startles easily during thunderstorms: A mild startle response, especially with a prior fear of storms, is not an urgent concern. While it may relate to trauma, it is not immediately dangerous or requiring urgent follow-up.

G. Friend reporting client is not themselves: Changes in behavior observed by peers can indicate worsening mental health or risk of self-harm. Immediate follow-up is important to evaluate mood, coping, and safety.

H. Smoking marijuana to clear their mind: Self-medicating with substances is a significant safety concern, particularly in adolescents coping with trauma. Immediate follow-up is required to assess for substance use disorder and potential harm to mental and physical health.