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 seizures

Paresthesias

Disorientation

Sleep apnea

Answer and Explanation

The Correct Answer is C

A. Tonic-clonic seizures: This is not typically expected following electroconvulsive therapy (ECT). ECT can induce a brief seizure during the procedure, but the nurse would not expect tonic-clonic seizures afterward as a direct result.

B. Paresthesias: Paresthesias (tingling or numbness) are not commonly associated with ECT. The procedure primarily affects the brain, and while some neurological symptoms may occur temporarily, paresthesias are not expected findings.

C. Disorientation: This is correct. It is common for clients to experience disorientation and confusion immediately following ECT, as it can affect memory and cognition temporarily. This typically resolves within a short period of time (minutes to hours) following the procedure.

D. Sleep apnea: Sleep apnea is not a direct or common effect of ECT. While anesthesia used during the procedure may cause some temporary respiratory changes, sleep apnea would not be expected as a typical post-procedure finding.

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Correct Answer is A

Explanation

A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.

B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.

A. The client's heart rate has increased to 110/min. B. The client grimaces when changing positions. C. The client reports pain as 7 on a scale of 0 to 10. D. The client demonstrates a decreased attention span.

Correct Answer is C

Explanation

A. The client's heart rate has increased to 110/min is incorrect. While an increased heart rate can indicate pain, it can also be caused by other factors such as anxiety, dehydration, or fever. Heart rate alone is not the most specific or reliable indicator for the need for analgesia.

B. The client grimaces when changing positions is a possible sign of discomfort, but the level of pain cannot be accurately assessed from facial expressions alone. This may suggest mild to moderate pain but does not provide a clear numerical indication of the client's pain level.

C. The client reports pain as 7 on a scale of 0 to 10 is correct. The pain scale is a more direct and reliable measure of the client's pain experience. A rating of 7 indicates moderate to severe pain, which justifies the need for analgesic intervention.

D. The client demonstrates a decreased attention span could be related to pain or discomfort, but it may also result from other causes, such as fatigue, emotional stress, or medication side effects. This is not as definitive as a self-reported pain level.

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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?

Nursing Test Bank

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