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A client who is to undergo electroconvulsive therapy for severe depression is quite anxious about the treatment and asks the nurse what to expect after treatment. Which of the following information should the nurse include? Select all that apply.
- A. The client will experience confusion for a short time.
- B. Headache and muscle soreness are common.
- C. Some degree of memory loss, usually transient, may occur.
- D. Possible urinary incontinence may occur for 12 hours.
- E. The client may experience hallucinations for 2 to 3 weeks.
Correct Answer: A,B,C
Rationale: ECT causes short-term confusion (A), headache/muscle soreness (B), and transient memory loss (C). Incontinence (D) and prolonged hallucinations (E) are not typical.
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The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- A. Speak using words that rhyme
- B. Repeat words or phrases used by others
- C. Include irrelevant details in conversation
- D. Make up new words with new meanings
Correct Answer: B
Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication processing.
A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:
- A. Draw a man in six parts
- B. Give his first and last name
- C. Dress without supervision
- D. Define a list of words
Correct Answer: B
Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin inhibits platelet aggregation, reducing the risk of clot formation in transient ischemic attacks, which are precursors to stroke.
A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
- A. Slow the infusion rate
- B. Make sure the client is well hydrated
- C. Record the intake and output every shift
- D. Tell the client to report ringing in the ears
Correct Answer: B
Rationale: Adequate hydration is critical to prevent cisplatin-induced nephrotoxicity by promoting renal excretion of the drug.
The physician prescribes captopril (Capoten) 25 mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
- A. Tinnitus
- B. Persistent cough
- C. Muscle weakness
- D. Diarrhea
Correct Answer: B
Rationale: Captopril, an ACE inhibitor, commonly causes a persistent dry cough.