Nokea
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.â€
- C. It's okay to be nervous before this treatment.
- D. You don't have to go through with the treatment.
Correct Answer: D
Rationale: Rationale: Option D is correct because it respects the client's autonomy and right to make decisions about their treatment. The client has the right to refuse treatment, even after giving initial consent. It is important for the nurse to support the client's decision without coercion.
Summary:
A: Incorrect. This statement does not address the client's current decision to refuse treatment.
B: Incorrect. This statement undermines the client's autonomy by implying they should follow the doctor's orders.
C: Incorrect. While acknowledging the client's feelings is important, it does not address the client's decision to refuse treatment.
D: Correct. Respects the client's autonomy and decision-making.
E, F, G: Not applicable.
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Which of the following actions should the nurse plan to take?
- A. Flush the NG tube with 30 ml D.9% sodium chloride before and after medication.
- B. Maintain the head of the bed at a 20° angle.
- C. Advance the rate of the feeding every 2 hr.
- D. Measure gastric residual volumes every 4 hr
Correct Answer: D
Rationale: Measuring residuals prevents aspiration risks.
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds
- C. Place the client in a high-Fowler's position
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (A) or placing them in a high-Fowler's position (C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.
Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. Malaise is a general feeling of discomfort or unease, commonly seen in various health conditions. In this scenario, malaise can be an expected manifestation due to its non-specific nature and association with underlying illnesses. Drooling (A), tinnitus (C), and rhinorrhea (D) are not typically associated with the given context and are less likely to be expected manifestations.
For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is essential in assessing neurological function and detecting abnormalities such as hyperreflexia or hyporeflexia. A normal response of 2+ indicates intact neurological pathways. Abnormal reflexes could be indicative of various neurological conditions. Pulse rate, urine output, and proteinuria are important parameters to monitor but are not specifically related to therapeutic effects. Monitoring deep tendon reflexes is crucial for detecting early signs of neurological complications and guiding appropriate interventions.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should keep the medication in the original container.
- B. I should replace any unused medication every 6 months.
- C. I can store the medication in the refrigerator.
- D. I can crush the medication and mix with applesauce.
Correct Answer: A
Rationale: The correct answer is A because keeping medication in the original container ensures proper identification, dosage, and expiration monitoring. Choice B is incorrect as replacing unused medication every 6 months may lead to waste. Choice C is incorrect as not all medications should be stored in the refrigerator. Choice D is incorrect as crushing medication may alter its effectiveness or cause harm. It is important for the client to understand the importance of following specific storage instructions provided with the medication, making choice A the most appropriate response.