A nurse is collecting data from a client who self-administers pilocarpine ophthalmic drops. Which of the following findings by the nurse indicates a systemic adverse effect of this medication?

Choice A rationale Urinary retention is an anticholinergic effect, often seen with medications that block the parasympathetic nervous system, such as atropine. Pilocarpine, however, is a cholinergic agonist, meaning it stimulates the "rest and digest" system. Therefore, it would more likely cause increased bladder contraction and urinary frequency or urgency rather than retention. Systemic absorption of pilocarpine would stimulate muscarinic receptors in the detrusor muscle of the bladder, facilitating voiding rather than inhibiting the ability to urinate. Choice B rationale Hypertension is typically associated with sympathetic nervous system stimulation. As a cholinergic agent, pilocarpine tends to have the opposite effect when it reaches systemic levels. It can cause vasodilation and a decrease in heart rate (bradycardia), which usually leads to hypotension rather than hypertension. The normal heart rate range is 60 to 100 beats per minute, and a systemic cholinergic overdose could drop the heart rate significantly, potentially leading to reduced cardiac output and low blood pressure. Choice C rationale Decreased salivation, or xerostomia, is a classic anticholinergic side effect. Since pilocarpine is a muscarinic agonist, it stimulates the salivary glands to increase production. In fact, pilocarpine is sometimes used orally to treat dry mouth in conditions like Sjogren's syndrome. Therefore, if a patient using pilocarpine eye drops experiences systemic absorption, they would be expected to have increased salivation or drooling rather than a dry mouth. This makes decreased salivation an incorrect clinical finding for this drug. Choice D rationale Diarrhea is a common systemic adverse effect of cholinergic medications like pilocarpine. When the medication is absorbed systemically, it stimulates the muscarinic receptors in the gastrointestinal tract, leading to increased peristalsis and secretions. This hypermotility results in abdominal cramping and frequent, loose stools. Monitoring for gastrointestinal distress is important for patients using pilocarpine, as it indicates that the drug is having a widespread effect beyond the local ocular tissue, necessitating a review of their administration technique.