A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?
Witness the client signing the form.
Discuss alternative treatment options with the client.
Determine the client is competent to give consent.
Discuss the benefits of ECT with the client.
The Correct Answer is A
A. One of the nurse's responsibilities during the informed consent process is to witness the client signing the consent form. This ensures that the client voluntarily agrees to undergo ECT after receiving adequate information about the procedure, its risks, benefits, and alternatives. By witnessing the signature, the nurse confirms that the client's consent is documented appropriately and legally.
B. Nurses may provide general information about ECT and its alternatives, but the detailed discussion about treatment options and their implications usually occurs during the consultation with the provider.
C. Determining if a client is competent to give consent is a legal determination typically made by a healthcare provider or a legal representative, not the nurse.
D. It is not the nurse's role to discuss the specific benefits of ECT, as these discussions are the responsibility of the healthcare provider leading the client's care.
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Correct Answer is D
Explanation
A. Lanugo refers to fine, soft hair that grows on the face, back, and arms as a result of malnutrition. It is more common in anorexia nervosa rather than bulimia nervosa.
B. Muscle wasting is not typically a primary symptom of bulimia.
C. Hypomagnesemia, or low magnesium levels, may occur but is not very characteristic of bulimia nervosa.
D. Hypokalemia, or low levels of potassium in the blood, is a common finding in individuals with bulimia nervosa who engage in purging behaviors such as vomiting or misuse of diuretics. Potassium is crucial for proper muscle and nerve function, and low levels can lead to symptoms such as muscle weakness, fatigue, cardiac arrhythmias, and in severe cases, paralysis.
Correct Answer is A
Explanation
A. Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B. Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.
C. Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D. Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.
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