A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

Orient the client and offer reassurance

Encourage the client to drink some fluids

Orient the client and monitor vital signs

Assist the client from the stretcher to a wheelchair

Answer and Explanation

The Correct Answer is C

C. After ECT, the client may be disoriented, confused, or drowsy due to the effects of anesthesia and the procedure itself. Orienting the client to their surroundings and situation helps promote their safety and comfort. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial to assess the client's immediate post-procedural status and detect any complications.
A. Offering reassurance can help alleviate any anxiety or confusion the client may experience. However, while this intervention is important, it may not be the first priority immediately upon admission to the Post Anesthesia Care Unit (PACU).
B. Hydration is important after any medical procedure, including ECT. However, immediately after ECT, the client may still be recovering from anesthesia and may not be fully alert or able to safely drink fluids.
D. Assisting the client with mobility is important but it may not be the first intervention performed in the PACU after ECT. The priority immediately upon admission to the PACU is to ensure the client's safety.

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Correct Answer is D

Explanation

D. This recognizes that the client's improvement in mood is a typical response to antidepressant medication and does not automatically suggest any negative outcomes such as suicidal ideation or serotonin syndrome.
A. It's important to be vigilant for signs of suicidal ideation but sudden improvements in mood can also occur as a positive response to antidepressant medication.
B. The client's description of feeling better does not align with the symptoms of serotonin syndrome, which include agitation, confusion, rapid heart rate, high blood pressure, and hyperthermia.
C. Antidepressant medications often take several weeks to reach their full therapeutic effect, so it's not unusual for some clients to experience an improvement in mood within the first few weeks of treatment.

A. use a high-quality heating pad for the pain. B. contact the primary care provider immediately. C. call an orthopedic doctor to evaluate the symptoms. D. start on a clear liquid diet and maintain bedrest.

Correct Answer is B

Explanation

B. The combination of paroxetine and St. John's Wort can lead to a potentially life-threatening condition known as serotonin syndrome. It is important for healthcare providers to be aware of potential drug interactions and to monitor patients closely when changes to their medication regimen occur.
A. Using a heating pad may provide temporary relief for muscle stiffness but does not address the underlying cause of the symptoms.
C. Given the symptoms described, involving an orthopedic doctor is not appropriate as the symptoms are not related to musculoskeletal issues.
D. A clear liquid diet and bed rest do not address the underlying issue in the client hence not an appropriate action.

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A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

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