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 C

Explanation

C. This statement demonstrates an understanding of the availability of support groups specifically for family members affected by alcohol use disorder and reflects the spouse's willingness to seek support independently of the client's readiness for treatment.
A. Effective teaching would convey that support groups are available not only for individuals struggling with alcohol use disorder but also for their family members who may need support in coping with the impact of the disorder on their lives.
B. Alcoholics Anonymous (AA) meeting are primarily for individuals with alcohol use disorder.
D. Effective teaching would emphasize the importance of the family seeking support for themselves independently of the client's readiness to seek treatment.

A. Request a psychiatric evaluation for the client B. Interview the client alone and assess for abuse C. Provide the daughter and client with nutritional counseling D. Take the history from the daughter because of the client's confusion

Correct Answer is B

Explanation

B. Given the client's confusion and the daughter's behavior of constantly interrupting and not allowing the client to answer, there may be concerns about elder abuse or neglect. It's essential to create a safe and private environment for the client to speak freely without interference.
A. The client's confusion and reluctance to speak may raise concerns about their mental status. However, requesting a psychiatric evaluation is not the priority in this scenario. The client's immediate needs, including hydration, nutrition, and safety, should be addressed first.
C. Addressing malnutrition is important but providing nutritional counseling is not the priority in this scenario. The client's severe dehydration and potential abuse or neglect take precedence over nutritional concerns.
D. Obtaining information from the daughter may be helpful but it should not be the sole source of information, especially if there are concerns about the daughter's behavior and potential interference with the client's ability to communicate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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