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A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?
- A. You will be given an opioid analgesic before the procedure.
- B. Expect to be confused several hours after the procedure.
- C. You cannot eat or drink for 24 hours before the procedure.
- D. A consent form is not required to have this procedure.
Correct Answer: B
Rationale: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.
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A nurse is caring for a client who has a phobia of elevators. Which of the following behavioral strategies should the nurse plan to use to decrease anxiety?
- A. Response prevention.
- B. Systematic desensitization.
- C. Thought stopping.
- D. Flooding.
Correct Answer: B
Rationale: Systematic desensitization is an effective behavioral strategy for decreasing anxiety related to specific phobias. This method involves gradually exposing the client to the feared object or situation—in this case, elevators—in a controlled and progressive manner while teaching relaxation techniques. By slowly and systematically confronting the phobia, the client can learn to reduce their anxiety response over time.
A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.
A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?
- A. A systolic blood pressure decrease of 15 mm Hg after standing
- B. Hypersalivation
- C. Tinnitus
- D. A weight loss of 3.6 kg (8 lb) over a 6-month time period
Correct Answer: A
Rationale: A decrease in systolic blood pressure of 15 mm Hg after standing could indicate orthostatic hypotension, which is a known adverse effect of amitriptyline. Orthostatic hypotension can lead to dizziness, lightheadedness, and falls, posing a significant risk to the patient's safety. Reporting this finding to the provider is crucial for assessing the need for dosage adjustments or alternative treatments.
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?
- A. This medication is known to cause dependence.
- B. Avoid consuming large amounts of leafy, green vegetables while taking this medication.
- C. It can take several weeks before you notice an effect from the medication.
- D. If a dose is missed, you can take the missed dose along with the next scheduled dose.
Correct Answer: C
Rationale: Buspirone typically takes several weeks to achieve its full therapeutic effect. Clients should be advised to continue taking the medication as prescribed and not to expect immediate relief of anxiety symptoms. This information helps set realistic expectations and encourages adherence to the treatment plan.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake, and I won't let it take all of my blood. Which of the following responses should the nurse make?
- B. Your provider requires this blood specimen.
- C. You must be mistaken. Snakes cannot be in the clinic.
- D. I'm using a syringe to obtain your blood, not a snake.
- E. I don't see a snake, but that must be scary for you.
Correct Answer: D
Rationale: Acknowledging the client's hallucination and expressing empathy is the most appropriate response. By saying, 'I don't see a snake, but that must be scary for you,' the nurse acknowledges the client's fear and provides comfort without reinforcing the hallucination. This approach helps build trust and rapport, making it easier to proceed with the necessary procedure while ensuring the client's emotional wellbeing.