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The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a diagnosis of major depressive disorder. Which assessment findings should the nurse identify as expected short-term side effects of ECT that do not require notifying the primary health care provider?
- A. Confusion
- B. Memory loss
- C. Hypertension
- D. Disorientation
- E. Heart palpitations
Correct Answer: A,B,D
Rationale: The major expected side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure or presence of heart palpitations would not be anticipated side effects and would be causes for concern. If hypertension or presence of heart palpitations occurred after ECT, the primary health care provider should be notified.
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A client diagnosed with nephrotic syndrome asks the nurse, 'Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do if I can never get rid of this kidney problem, anyway!' Which should the nurse identify as the most appropriate concern for this client?
- A. Anxiety
- B. Powerlessness
- C. Difficulty coping
- D. Negative self-image
Correct Answer: B
Rationale: Powerlessness is present when the client believes that personal actions will not affect an outcome in any significant way. Because nephrotic syndrome is progressive, the client may feel that personal actions may not affect the disease process. Anxiety is appropriate when the client has a feeling of unease with a vague or undefined source. Difficulty coping occurs when the client has impaired adaptive abilities or behaviors with regard to meeting expected demands or roles. Negative self-image is when there is an alteration in the way that the client perceives his or her body image.
A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, 'If my doctor tells me to do it, I will. Otherwise, I won't.' Which behavior should the nurse determine that the client is displaying?
- A. Anger
- B. Denial
- C. Depression
- D. Dependency
Correct Answer: D
Rationale: Clients may experience numerous emotional and behavioral responses after an MI. Dependency is one response that may be manifested by the client's refusal to perform any tasks or activities unless specifically approved by the primary health care provider. Although the client's statement may express anger to some degree, it most specifically addresses dependency. There are no data in the question to support denial or depression.
The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed?
- A. Psychodrama
- B. Reality therapy
- C. Psychoanalytic therapy
- D. Short-term dynamic psychotherapy
Correct Answer: A
Rationale: Psychodrama involves the enactment of emotionally charged situations. Reality therapy is used for individuals with cognitive impairment. Both short-term dynamic psychotherapy and psychoanalytic therapy depend on techniques that are drawn from psychoanalysis.
A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
- A. Ongoing fluid restriction
- B. The need for genetic counseling
- C. The risk of hypotensive episodes
- D. Depression regarding massive edema
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?
- A. Guided imagery and limiting fluids
- B. Relaxation and breathing techniques
- C. Biofeedback and coughing techniques
- D. Distraction and increased dietary carbohydrates
Correct Answer: B
Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.