Question

Ann, 17 years old, was prescribed an antidepressant 3 weeks ago. Her father brings her to the Emergency Department because she has not been eating or sleeping and has been irritable since last week. She presents with rapid speech, dizziness, dry mouth and increased energy. When assessing Ann, what should the nurse do first.

a) ask what medication including vitamins, she has taken and if she has consumed any illicit drugs or alcohol.

b) review Ann’s health history, obtain a urine sample for drug screening and ask her to try to relax.

c) obtain the bottle of medication that Ann has been taking and ask her father if she has used illicit drugs.

d) complete a health history and ask Ann to wait in the hall until the physician arrives.

Answer 1

c) obtain the bottle of medication that Ann has been taking and ask her father if she has used illicit drugs.

These are the important things the nurse should include in conducting assessment, history taking, and examination:

Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal diseases, psychosis, glaucoma, etc.) to prevent any untoward complications.

Assess for history of seizure disorders, psychiatric problems, suicidal thoughts and myelography within the past 24 hours or in the next 48 hours to avoid potentially serious adverse reactions.

Perform a thorough physical assessment to establish baseline data before drug therapy begins, to determine the effectiveness of therapy, and to evaluate for the occurrence of any adverse effects associated with drug therapy.

Monitor results of electrocardiogram and laboratory tests (e.g. renal and liver function tests) to monitor the effectiveness of the therapy and provide prompt treatment to developing complications.