A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder, which of the following findings should the nurse expect 15 min following the procedure?
Tonic-clonic satures
Sleep apnea
Paresthesias
Disorientation
The Correct Answer is D
Rationale:
A. Tonic-clonic seizures: Tonic-clonic activity is induced during the ECT procedure itself but typically resolves within seconds. It is not expected to persist 15 minutes post-procedure, as seizure activity is carefully controlled and monitored during the treatment.
B. Sleep apnea: While general anesthesia used during ECT can cause brief respiratory depression, sleep apnea is not a typical or expected consequence of the procedure. Continuous monitoring ensures airway patency during and immediately after treatment.
C. Paresthesias: Numbness or tingling sensations (paresthesias) are not common side effects of ECT. The procedure affects brain activity and cognition rather than peripheral nerves, making this symptom unlikely post-treatment.
D. Disorientation: Temporary confusion or disorientation is a common and expected side effect shortly after ECT. It typically resolves within 30 to 60 minutes as the effects of anesthesia wear off, and it is routinely monitored during recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Orange juice: Orange juice contains minimal sodium and is typically recommended for clients needing low-sodium, high-potassium diets. It is not considered a significant source of sodium.
B. Canned green beans: Canned vegetables often contain added salt as a preservative, making them high in sodium. Unless labeled as low-sodium or no-salt-added, canned green beans are among the higher sodium food options.
C. Sweet potato: Sweet potatoes are naturally low in sodium and are more commonly recognized for their potassium and fiber content. They are suitable for low-sodium diets.
D. Cantaloupe: Cantaloupe is a low-sodium fruit, valued for its high water and potassium content. It is not a source of concern for clients with sodium restriction or imbalance.
Correct Answer is D
Explanation
Rationale:
A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.
B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.
C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.
D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.
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