Nokea
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
- A. monitor the airway and be prepared to provide suction if needed
- B. continuously observe vital signs and cardiac function on the monitor
- C. provide support and safe positioning to the client's arms and legs during the seizure
- D. record the type, frequency, duration, and amount of movement induced by the seizure
Correct Answer: A
Rationale: Airway management is the priority during ECT due to the risk of aspiration or respiratory compromise during induced seizures.
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During the nurse's shift in the emergency department, a nurse assesses a client who is suspected of being under the influence of opioids. Which symptom is indicative of opioid use?
- A. hypotension
- B. diaphoresis
- C. shallow respirations
- D. outbursts of anger
Correct Answer: C
Rationale: Shallow respirations are a hallmark of opioid intoxication due to respiratory depression.
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?
- A. Ask a family member to stay with the client during the procedure.
- B. Give the client the call bell, and encourage its use if the client feels worse.
- C. Leave the client alone only to gather the required equipment and medications.
- D. Stay with the client, and ask another nurse to gather needed equipment and supplies.
Correct Answer: D
Rationale: The client with pulmonary edema is experiencing severe anxiety, which can exacerbate the condition and hinder treatment. Staying with the client provides emotional support and reassurance, addressing the psychosocial aspect of care, while delegating equipment gathering ensures efficient preparation for treatment. This holistic approach meets both the emotional and physical needs of the client. Option 1 may not be feasible or sufficient to address immediate anxiety. Option 2 does not provide active support, and option 3 leaves the client alone, which could increase anxiety.
A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.
The nurse is caring for a terminally ill woman who is dying from diagnosed breast cancer. The nurse should know which client behavior is characteristic of anticipatory grieving?
- A. Discusses thoughts and feelings related to loss
- B. Has prolonged emotional reactions and outbursts
- C. Verbalizes unrealistic goals and plans for the future
- D. Ignores untreated medical conditions that require treatment
Correct Answer: A
Rationale: The nurse can determine the client's stage of anticipatory grief by observing the client's behavior. The remaining options are examples of dysfunctional grieving.
After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns?
- A. The United Way
- B. The client's local church
- C. The American Cancer Society Reach for Recovery
- D. The American Heart Association Mended Hearts Club
Correct Answer: D
Rationale: Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy.