A nurse is caring for a client who is taking amitriptyline. The nurse should monitor for which of the following adverse effects?

Drooling

Orthostatic hypotension

Diarrhea

Metallic taste in mouth

Answer and Explanation

The Correct Answer is B

Choice A reason: Drooling is not a common side effect of amitriptyline; instead, dry mouth due to anticholinergic effects is more likely.

Choice B reason: Orthostatic hypotension is a well-documented adverse effect of amitriptyline, related to its action on the autonomic nervous system. Nurses should closely monitor for dizziness, falls, or fainting.

Choice C reason: Diarrhea is not a typical adverse effect of amitriptyline; constipation is more commonly seen because of anticholinergic properties.

Choice D reason: Metallic taste in the mouth is not a notable adverse effect of amitriptyline and is more often associated with other medications such as certain antibiotics.

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Correct Answer is A

Explanation

Choice A reason:Regression involves reverting to an earlier developmental stage under stress, such as seeking dependency or avoiding responsibilities like chores and appointments. The client’s desire to be cared for reflects this defense mechanism.

Choice B reason:Introjection involves internalizing others’ beliefs or values, such as adopting someone else’s attitudes. The client’s behavior does not involve adopting external values but rather a retreat to dependency.

Choice C reason:Repression involves unconsciously blocking distressing thoughts or memories. The client’s behavior is not about forgetting stress but actively expressing a need for care, making this incorrect.

Choice D reason:Dissociation involves detaching from reality or one’s sense of self, often in response to trauma. The client’s behavior reflects dependency, not a disconnection from reality, so this is incorrect.

A. Ask the client to describe the situation. B. Give the client a bed bath prior to physical examination. C. Discuss self-defense techniques with the client. D. Inform the client photographs of injuries are required for a police report.

Correct Answer is A

Explanation

Choice A reason: Allowing the client to describe the event in their own words is essential for initial assessment, evidence collection, and emotional support.

Choice B reason: A bed bath would destroy physical evidence needed for forensic examination.

Choice C reason: Discussing self-defense techniques at this time is inappropriate, as the focus should be on immediate safety, support, and care.

Choice D reason: Photographs may be taken, but the nurse should not present them as required for police reporting, as this can increase trauma and coercion.

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A nurse is caring for a client who is taking amitriptyline. The nurse should monitor for which of the following adverse effects?

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