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?

Sleep apnea

Disorientation

Tonic-clonic seizures

Paresthesias

Answer and Explanation

The Correct Answer is B

Disorientation is a common side effect of ECT and is typically temporary. It may include confusion and difficulty recalling recent events or personal information. This post-treatment disorientation is often referred to as the "postictal state" and usually resolves within a short period of time.

Sleep apnea, tonic-clonic seizures, and paresthesias are not expected findings following ECT and would require immediate attention and intervention if they were to occur. It is important for the nurse to closely monitor the client's vital signs, oxygen saturation levels, and neurological status after the procedure to ensure their safety and well-being.

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Correct Answer is A

Explanation

Fever.

Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. The characteristic symptoms of pertussis include paroxysmal (severe and uncontrollable) coughing fits, followed by a "whooping" sound during inhalation as the child tries to catch their breath. However, specific manifestations may vary depending on the stage of the illness.

Fever is a common manifestation of pertussis. The child may have an elevated body temperature as a response to the infection. The fever is typically low-grade but can occasionally be higher.

Koplik spots in (option B) is incorrect because they are small white or bluish-grey spots with a red halo that appear on the inside of the cheeks. However, Koplik spots are characteristic of measles (rubeola) and not pertussis.

Facial erythema, or redness of the face, in (option C) is incorrect because it is not a typical manifestation of pertussis. Facial redness may be seen in other conditions such as fever, allergic reactions, or certain skin conditions.

A beefy, red tongue Is in (option D) is incorrect because it is not associated with pertussis. This description is more commonly associated with other conditions such as vitamin B12 deficiency or certain types of oral infections.

A. Caution the client to avoid a prone position while in bed. B. Keep a loose, absorbent dressing over the client's surgical site. C. Maintain abduction of the client's residual limb with a pillow. D. Encourage the client to use the overbed trapeze

Correct Answer is D

Explanation

Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.

Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.
Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence.
Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.

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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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