Nokea
The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:
- A. Monitoring for the return of the capacity for full range of motion.
- B. Assessing the degree of accumulating memory impairment.
- C. Making positive comments while the patient is more receptive.
- D. Assessing the level of consciousness and normal body functions.
Correct Answer: D
Rationale: The correct answer is D: Assessing the level of consciousness and normal body functions. After electroconvulsive therapy (ECT), it is crucial to monitor the patient's level of consciousness and ensure all body functions are normal to detect any potential complications immediately. This includes assessing vital signs, neurological status, respiratory function, and cardiovascular stability. Monitoring for the return of full range of motion (A) is not a priority immediately post-ECT. Assessing memory impairment (B) may be important but is not the immediate priority. Making positive comments (C) is helpful for emotional support but does not address the critical need to assess physical status.
You may also like to solve these questions
The nurse in the Emergency Department is taking a history from a family accompanying a child with suspicious traumatic injuries. The nurse should:
- A. Obtain information as covertly as possible
- B. Avoid responding to hints that abuse has occurred
- C. Be open, concerned, and honest
- D. Separate the family from the child during the interview
Correct Answer: C
Rationale: The correct answer is C because being open, concerned, and honest fosters trust, encourages disclosure, and promotes a supportive environment for the family. This approach allows the nurse to gather necessary information effectively and ensure the safety and well-being of the child. Choice A is incorrect as covert behavior may lead to suspicion and hinder communication. Choice B is incorrect because ignoring hints of abuse can be detrimental to the child's safety. Choice D is incorrect as separating the family may escalate tension and prevent crucial information sharing.
A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as:
- A. Altered mood states
- B. Disturbed thinking
- C. Social isolation
- D. Poor impulse control
Correct Answer: B
Rationale: The correct answer is B: Disturbed thinking. In this scenario, the client's belief that her thoughts cause earthquakes and the world is burning are examples of delusions, which are a key symptom of schizophrenia. This demonstrates a disturbance in the client's thought process, indicating a primary deficit in thinking. Altered mood states (A) may be present as well but are not the primary deficit in this case. Social isolation (C) is a consequence of the client's symptoms rather than the primary deficit. Poor impulse control (D) is not the primary issue presented in the scenario.
Persons who suffer from paraphilias are categorized as having
- A. somatoform disorders
- B. generalized anxiety
- C. sexual disorders
- D. personality disorders
Correct Answer: C
Rationale: Paraphilias are classified as sexual disorders, involving atypical sexual interests causing distress or harm.
The wife of a client who is being seen in the sleep clinic states that her husband snores terribly at night and that she has to shake him to get him to stop. The client complains of a headache upon wakening and often falls asleep during the day when he sits for long periods. This client is exhibiting signs and symptoms characteristic of:
- A. narcolepsy.
- B. parasomnia.
- C. sleep apnea.
- D. primary hypersomnia.
Correct Answer: C
Rationale: The correct answer is C: sleep apnea. The client's symptoms of loud snoring, need to be shaken to stop snoring, morning headache, daytime sleepiness, and falling asleep during the day are all classic signs of sleep apnea. Sleep apnea is a disorder characterized by pauses in breathing or shallow breathing during sleep, leading to poor sleep quality and daytime symptoms. Narcolepsy (choice A) involves excessive daytime sleepiness and sudden muscle weakness, which are not mentioned here. Parasomnia (choice B) refers to abnormal behaviors during sleep, such as sleepwalking or night terrors, which are not described in the scenario. Primary hypersomnia (choice D) is characterized by excessive daytime sleepiness without a clear cause, which is not consistent with the client's symptoms.
A patient diagnosed with schizophrenia reveals to the nurse that voices have warned of danger and adds, 'They're so loud they frighten me. Do you hear them?' The nurse's best initial response would be:
- A. I know these voices are very real to you, but I don't hear them.'
- B. Don't worry. You're safe in the hospital. I won't let anything happen to you.'
- C. Tell me more about the voices. Are they men or women? How many are there?'
- D. What do you do in order to keep yourself occupied so you don't hear the voices?'
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's experience without dismissing or invalidating it. By stating, "I know these voices are very real to you, but I don't hear them," the nurse validates the patient's reality and expresses empathy. This response helps build trust and rapport, which is crucial in establishing a therapeutic relationship.
Choice B is incorrect because it dismisses the patient's concerns and offers false reassurance, which may not be effective in addressing the patient's distress.
Choice C is incorrect as it focuses on gathering more information about the voices without addressing the patient's immediate emotional distress.
Choice D is incorrect because it shifts the focus away from the patient's current experience and onto distractions, which may not be helpful in addressing the patient's distressing symptoms.