A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

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.

Rationale for Correct Choices:

• Intravenous antibiotic: The client shows multiple signs of endometritis: uterine tenderness, foul-smelling lochia, fever, tachycardia, and elevated WBC count. IV antibiotics are the first-line treatment for postpartum uterine infections, particularly after cesarean delivery with risk factors like prolonged rupture of membranes.
• Increase in daily fluid intake: Clients with infection and fever require increased hydration to support perfusion, manage elevated metabolic demands, and help clear the infection. Fever and poor bowel motility may also contribute to mild dehydration, making fluid support essential.

Rationale for Incorrect Choices:

• Intrauterine tamponade balloon: This is used to control postpartum hemorrhage due to uterine atony or trauma. Although the fundus was boggy, it firmed with massage, and there is no indication of active or excessive bleeding, making tamponade unnecessary.
• Kleihauer-Betke test: This test detects fetal blood in the maternal circulation and is used after trauma or suspected fetal-maternal hemorrhage, especially in Rh-negative mothers. It is not relevant to this postpartum infection scenario.
• Tocolytic medication: Tocolytics are used during pregnancy to suppress preterm labor by relaxing the uterus. In the postpartum period, they are not indicated and would be contraindicated in the presence of infection, as they can reduce uterine tone and worsen involution.