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Which intervention will the nurse implement in the first half hour after the patient has received ECT?
- A. Continually stimulate patient to respond, using physical and verbal means.
- B. Continue bagging patient to improve respiratory function until patient is responsive for 10 minutes.
- C. Reorient as necessary to time, place, and person as level of consciousness improves.
- D. Encourage walking and eating breakfast as quickly as possible.
Correct Answer: C
Rationale: The correct answer is C because reorienting the patient to time, place, and person is crucial in the immediate post-ECT period to help the patient regain orientation as consciousness improves. This intervention helps prevent confusion and disorientation commonly experienced after ECT. A: Continually stimulating the patient may be overwhelming and unnecessary. B: Continuing bagging is not relevant after ECT as the patient's respiratory function should have stabilized. D: Encouraging walking and eating can be unsafe immediately post-ECT due to potential disorientation and muscle weakness.
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The nurse is collecting the paintings from the patients after the art session is over. After art therapy, a patient hands the nurse a paper that consists of several black scribbles. Which statement demonstrates the nurse understands the goals and objectives of the therapy?
- A. “I see that you don’t take this very seriously.”
- B. “Can you tell me what happened to prompt such work?”
- C. “Do you want to complete your painting?”
- D. “That’s interesting. It looks like you’re frustrated.”
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and encouragement for the patient to express their feelings. By asking what prompted the artwork, the nurse demonstrates understanding and willingness to explore the patient's emotions. Choice A is judgmental and dismissive, not fostering a therapeutic relationship. Choice C is directive and may pressure the patient. Choice D makes an assumption about the patient's emotions without allowing them to share their perspective.
An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?
- A. Ask questions that can be answered with yes or no.
- B. Use silence often and let the patient take the lead.
- C. Use open-ended, indirect questions.
- D. Ask clear, simple questions using concrete language.
Correct Answer: D
Rationale: The correct answer is D: Ask clear, simple questions using concrete language. This strategy is most helpful because older adults with schizophrenia may have cognitive impairments that affect their ability to process complex information. Clear and simple questions using concrete language can help the patient understand and respond effectively.
Choice A (Ask questions that can be answered with yes or no) limits communication and may not provide enough information for the nurse to assess the patient's condition comprehensively. Choice B (Use silence often and let the patient take the lead) may not be effective as the patient may struggle to communicate effectively due to cognitive impairments. Choice C (Use open-ended, indirect questions) may lead to confusion or misinterpretation for a patient with cognitive challenges.
A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse’s rationale for this procedure?
- A. To prevent increased intracranial pressure resulting from anoxia
- B. To prevent anoxia due to medication-induced paralysis of respiratory muscles
- C. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation
- D. To prevent blocked airway resulting from seizure activity
Correct Answer: B
Rationale: The correct answer is B: To prevent anoxia due to medication-induced paralysis of respiratory muscles. During electroconvulsive therapy, muscle relaxants are often used to prevent injury during the seizure. These medications can lead to paralysis of respiratory muscles, causing potential anoxia if oxygen is not administered. Providing pure oxygen ensures adequate oxygenation despite muscle paralysis.
Incorrect Choices:
A: Preventing increased intracranial pressure is not the primary rationale for administering oxygen during ECT.
C: Hypotension, bradycardia, and bradypnea are potential side effects of ECT itself, but oxygen administration is not primarily to prevent these.
D: Oxygen is not administered to prevent a blocked airway but rather to ensure adequate oxygenation during muscle paralysis.
Planning for a patient with Asperger's disorder will be facilitated if the nurse understands that this disorder is different from autism. The nurse will base care on knowledge that Asperger's disorder is characterized by:
- A. Repetitive patterns of behavior
- B. Age-appropriate language development.
- C. Stereotypic movements and speech patterns
- D. Obsession with objects that move in a spinning motion
Correct Answer: B
Rationale: The correct answer is B: Age-appropriate language development. Asperger's disorder is characterized by normal to above-average language development, whereas autism typically presents with delays or impairments in language skills. This is important for planning care as it influences communication strategies and interventions for individuals with Asperger's.
A: Repetitive patterns of behavior are more indicative of autism, not specific to Asperger's.
C: Stereotypic movements and speech patterns are also more associated with autism and not a defining feature of Asperger's.
D: Obsession with objects that move in a spinning motion is a specific behavior that may be seen in some individuals with autism, but it is not a defining characteristic of Asperger's disorder.
Planning safety interventions for a teenager with a history of self-injurious behavior is based on what research-based information?
- A. Teenagers rarely entertain the idea of suicide.
- B. Self-injury is always viewed as a risk factor for future suicidal attempts.
- C. Assessment for suicidal ideations is a vital component of this child's care.
- D. Suicides can occur accidentally as a result of self-injurious behaviors.
Correct Answer: D
Rationale: The correct answer is D because research indicates that suicides can occur accidentally as a result of self-injurious behaviors. This is known as an unintentional suicide, where the individual did not intend to die but died due to the severity of their self-injurious behavior. This information is crucial for planning safety interventions for the teenager, as it highlights the potential seriousness of self-injury.
Choice A is incorrect because research shows that suicidal ideation is not uncommon among teenagers, so it cannot be assumed that they rarely entertain the idea of suicide. Choice B is also incorrect because while self-injury can be a risk factor for future suicidal attempts, it is not always the case. Choice C is relevant but not the most specific to the scenario presented in the question, as it focuses solely on suicidal ideations rather than the potential accidental outcomes of self-injury.