A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?

Tremors: This choice is correct. Tremors or muscle twitching can be expected in a client experiencing acute cocaine toxicity. Cocaine is a central nervous system stimulant that can cause overstimulation of muscles, resulting in tremors.

Incorrect:

A- Hypothermia: This choice is incorrect. Acute cocaine toxicity is associated with an increase in body temperature (hyperthermia) rather than a decrease (hypothermia). Cocaine is a stimulant that can cause the body to overheat, leading to hyperthermia, which is a dangerous condition that requires immediate medical attention.

B- Hypotension: This choice is incorrect. Cocaine is a stimulant that increases blood pressure and heart rate, leading to hypertension (high blood pressure), not hypotension (low blood pressure). Hypertension is a common cardiovascular effect of cocaine use.

D- Respiratory depression: This choice is incorrect. Respiratory depression, which is a slowing of the respiratory rate and depth, is more commonly associated with depressant drugs like opioids or benzodiazepines. As a stimulant, cocaine tends to have the opposite effect, leading to increased respiratory rate (tachypnea) and sometimes hyperventilation.

In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.

Incorrect:

B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.

C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.

D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.