A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT) asks her mentor, “What sort of memory impairment is present after several ECT treatments?” The best response for the mentor would be:
- A. “It’s hard to say. Treatment affects everyone differently.”
- B. “Usually the patient has severe difficulty remembering remote events.”
- C. “Patients have mild difficulty remembering recent events, like what waseaten for breakfast.”
- D. “Both recent and remote memory is affected, producing profound confused, cognitive
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the typical memory impairment after ECT treatments. ECT affects both recent and remote memory, leading to profound confusion and cognitive difficulties. This is due to the disruption of neural pathways involved in memory consolidation and retrieval.
Choice A is incorrect as ECT does have predictable effects on memory. Choice B is incorrect because patients typically have more difficulty with recent memory than remote memory. Choice C is also incorrect as patients usually experience more than just mild difficulty remembering recent events; the memory impairment is more severe than just forgetting what was eaten for breakfast.
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A patient attending group therapy mentions, “In the beginning, I was so sick that everyone had to help me. For the last few days, it’s felt good to be able to give something back to the group.” This statement can be assessed as an example of Yalom’s factor of:
- A. Cohesiveness
- B. Imitative behavior
- C. Altruism
- D. Harmonizing
Correct Answer: C
Rationale: The correct answer is C: Altruism. This statement reflects the concept of altruism in group therapy, as the patient expresses the satisfaction of being able to give back to the group after receiving help in the beginning. Altruism refers to the unselfish concern for the well-being of others. In this case, the patient's experience of feeling good by being able to contribute positively to the group reflects a sense of altruism.
Choices A, B, and D are incorrect:
A: Cohesiveness is the sense of belonging and unity within a group, which is not directly reflected in the patient's statement.
B: Imitative behavior involves mimicking the actions of others, which is not evident in the patient's statement.
D: Harmonizing refers to the process of resolving conflicts and reaching agreement, which is not explicitly mentioned in the patient's statement.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority?
- A. Implement suicide precautions.
- B. Offer high-calorie snacks and fluids frequently
- C. Assist the patient to identify three personal strengths.
- D. Observe the patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: The correct answer is A: Implement suicide precautions. This is the highest priority because the patient has a plan for suicide, which poses an immediate risk to their safety. Implementing suicide precautions involves ensuring the patient's environment is safe, removing any potential means of self-harm, and closely monitoring the patient to prevent any suicide attempts.
Choice B is incorrect because offering high-calorie snacks and fluids frequently addresses the physical aspect of weight loss but does not address the immediate safety concern of suicide.
Choice C is incorrect because assisting the patient to identify personal strengths is important for building self-esteem but is not the highest priority when the patient is at risk for suicide.
Choice D is incorrect because observing the patient for therapeutic effects of antidepressant medication is important but not as urgent as ensuring the patient's safety in the case of suicidal ideation.
Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for general anesthesia. The nurse should follow these steps for this procedure (place in the order they will occur):
- A. Monitor the patients vital signs before the procedure.
- B. Medicate as prior to procedure if ordered.
- C. Educate patient and patients family.
- D. Check a signed consent
Correct Answer: C
Rationale: Rationale:
1. Educating the patient and family is crucial as it helps alleviate anxiety and ensures informed consent.
2. Monitoring vital signs (A) should be done before, during, and after the procedure, not necessarily in a specific order.
3. Medication administration (B) should be based on physician's orders but is not the initial step.
4. Checking a signed consent (D) is important but typically done before proceeding with any procedure, not necessarily in a specific order.
A patient is scheduled to attend an occupational therapy group to work on the identified goal of “recognizing and using more effective coping techniques.” What measure can the nurse use to continue to support the patient’s attainment of this goal after he returns to the unit?
- A. Praising him for positive behavioral changes
- B. Avoiding setting limits that would increase his anxiety level
- C. Isolating him from more seriously ill patients
- D. Recommending that he avoid group activities for a while
Correct Answer: A
Rationale: The correct answer is A: Praising him for positive behavioral changes. This measure reinforces the patient's use of effective coping techniques, providing positive feedback and motivation. This positive reinforcement encourages the patient to continue utilizing these strategies.
Choices B, C, and D are incorrect:
B: Avoiding setting limits that would increase his anxiety level - This does not actively support the patient's goal of recognizing and using more effective coping techniques.
C: Isolating him from more seriously ill patients - Isolation does not promote the practice of coping techniques and may hinder the patient's social interaction and progress.
D: Recommending that he avoid group activities for a while - Avoiding group activities contradicts the goal of attending occupational therapy groups and working towards improved coping techniques.
The nurse is assessing a child with autism. Which of the following behaviors would the nurse expect to observe?
- A. Referring to their imaginary friend, Skipper
- B. Asking to telephone my friends on the weekends
- C. Repeating, milk, milk, milk, milk until given a drink.
- D. Is insistent that a dim light be left on in the bedroom at night
Correct Answer: C
Rationale: The correct answer is C: Repeating, milk, milk, milk, milk until given a drink. This behavior is a characteristic of children with autism, known as echolalia. Echolalia is the repetition of words or phrases spoken by others, often used by individuals with autism to communicate or self-soothe. This behavior is a common feature of autism spectrum disorder and is indicative of language difficulties and communication challenges.
Choices A, B, and D are incorrect because they do not specifically relate to behaviors typically observed in children with autism. Referring to an imaginary friend (A) is not exclusive to autism, asking to telephone friends on weekends (B) is a social behavior that can be seen in children without autism, and insisting on a dim light in the bedroom (D) is a preference that does not directly relate to the core characteristics of autism.
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