A nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data from the client.

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

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and

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indicate manifestations of borderline personality disorder.

A. Measure the duration of the seizure. Monitoring the duration of a seizure is critical in determining whether it is self-limiting or prolonged. Seizures lasting longer than five minutes may indicate status epilepticus, requiring emergency intervention. Documenting the start and end times helps guide appropriate medical management.
B. Restrain the client's arms and legs to prevent injury. Restraining a client during a seizure can cause musculoskeletal injury or increase agitation. Instead, the nurse should ensure the client is in a safe position, remove nearby hazards, and allow the seizure to run its course while protecting the head.
C. Insert an oral airway into the client's mouth. Forcing an airway device or object into a seizing client's mouth can cause oral trauma, aspiration, or obstruction. The priority is to maintain a patent airway by positioning the client on their side to allow secretions to drain and prevent aspiration.
D. Lower the side rails of the bed when the seizure begins. Lowering the side rails increases the risk of the client falling out of bed during convulsions. If the client is already in bed, keeping the side rails up and padded can help prevent injury while allowing safe observation of the seizure activity.

A. Neck pain can occur in some patients following electroconvulsive therapy (ECT) due to muscle tension or positioning during the procedure. However, it is not a common or expected adverse reaction associated with ECT, so it is not the primary concern to address.
B. Temporary memory loss is a well-documented adverse reaction following ECT. Patients may experience difficulties with short-term memory, particularly related to events that occurred around the time of the treatment. This memory loss is usually temporary, but it can be distressing for some individuals.
C. Voice alteration is not typically associated with ECT. Although some patients may experience hoarseness or changes in vocal quality due to intubation or anesthesia, this is not a direct result of ECT itself and is not commonly mentioned in the context of ECT side effects.
D. Tingling of the scalp is not a recognized adverse reaction to ECT. Patients may experience various sensations, but tingling is not a common or documented response. The primary focus should be on more significant effects, such as temporary memory loss and potential confusion immediately following the treatment.