A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin.

For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

a.Ferrous sulfateworks best when you take it on an empty stomach. However, taking ferrous sulfate on an empty stomach can actually increase the risk of gastrointestinal side effects, such as nausea. It is often recommended to take it with food to reduce nausea, even though absorption is best on an empty stomach. Thus, this statement does not indicate proper understanding.

b.Black stools are a common side effect of taking iron supplements and are usually not a cause for concern unless they are tarry or associated with other symptoms, which could indicate gastrointestinal bleeding. Reporting black stools to the doctor is typically not necessary unless the stool is tarry and has other concerning symptoms like abdominal pain or bleeding. This statement reflects a misunderstanding of common side effects.

c.Mixing ferrous sulfate elixir with a full glass of water is advisable because it helps dilute the medication, making it easier to swallow and reducing the risk of gastrointestinal irritation. This practice also ensures that the medication is taken completely. This statement indicates a correct understanding of how to take the medication properly.

d.While staying hydrated can help manage constipation, milk is not recommended with iron supplements because calcium in milk can interfere with the absorption of iron. Instead, increasing water intake, eating a high-fiber diet, and considering other dietary measures would be better advice for preventing constipation.

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries.This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.