A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

Choice A reason

Empowering the client to feel in charge of his life is essential for promoting coping and a sense of control over the situation. However, it may not be the first priority when the client's safety is in question.

Choice B reason:

Finding the client, a temporary shelter where he can feel safe is important for meeting the client's immediate physical needs, but it can be addressed after ensuring his emotional well-being and safety.

Choice C reason

The client's partner has died in a traumatic event, and the loss of both a loved one and their home can be emotionally overwhelming and distressing. The nurse's first priority should be to assess the client's safety and well-being, especially considering the potential for thoughts of self-harm or suicide.

Assessing for thoughts of self-harm is critical because the client may be experiencing intense grief, guilt, or hopelessness, which can increase the risk of self-harm or suicidal ideation. Identifying these thoughts early allows the nurse to initiate appropriate interventions, provide emotional support, and involve mental health professionals if necessary.

Choice D reason

Reviewing the client's available social support system is significant for addressing the client's emotional needs and establishing a support network. However, ensuring the client's safety takes precedence over this action.

B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.

A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.

D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.

C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.