A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make?
"The most common side effects are directly related to the use of anesthesia."
The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss."
"Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure."
"Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen."
The Correct Answer is B
A. While anesthesia is used, the side effects from it are not the main concern with ECT.
B. The most common side effects are mild confusion, headache, and short-term memory loss, which are typically temporary.
C. Muscle relaxants are given before the procedure to prevent cramping or injury from the seizure.
D. Myocardial infarction is not a common side effect; this response could unnecessarily alarm the spouse.
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Related Questions
Correct Answer is D
Explanation
A. Occasional toileting accidents may be developmentally normal at age 3 and are not specific to autism spectrum disorder (ASD).
B. Interrupting or intruding on others is more consistent with ADHD than autism.
C. Crying when separated from a parent is typical of separation anxiety, not autism.
D. Repetitive motor behaviors such as rocking, hand-flapping, or spinning are characteristic of autism spectrum disorder. These stereotypical movements are used for self-stimulation and regulation.
Correct Answer is B
Explanation
A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.
B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.
C. This is judgmental and blaming, which is not therapeutic and may increase hostility.
D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.
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