A nurse is caring for a client who has received nine electroconvulsive therapy (ECT) treatments and reports short-term memory loss. Which of the following responses should the nurse make?

Memory loss is common and usually improves after a few weeks.

"You will likely experience long-term memory loss as well."

"You should focus on how much better you feel."

"I am going to notify your provider about your memory loss."

Answer and Explanation

The Correct Answer is A

Memory loss is a known side effect of electroconvulsive therapy (ECT), particularly in the short term. It is important for the nurse to provide accurate information to the client about this

potential side effect. Assuring the client that memory loss is common and tends to improve over time can help alleviate their concerns and provide reassurance. It is important to convey that this is a temporary effect and not necessarily indicative of long-term memory problems.

The other options are not appropriate responses:

B. "You will likely experience long-term memory loss as well": This statement provides inaccurate and potentially alarming information. While some individuals may experience persistent memory issues, it is not appropriate to assume or predict long-term memory loss in every case.

C. "You should focus on how much better you feel": This response dismisses the client's concerns about memory loss and may not address their needs or worries adequately. It is important to acknowledge and validate the client's experience.

D. "I am going to notify your provider about your memory loss": While it is important for the nurse to communicate any concerning symptoms to the client's healthcare provider, simply stating this without providing further information or reassurance may increase the client's anxiety without addressing their immediate concerns about memory loss.

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Correct Answer is B

Explanation

By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.

Let's review the other options and explain why they are not appropriate in this situation:

A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.

C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.

D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.

A. Displacement B. Reaction formation C. Denial D. Rationalization

Correct Answer is C

Explanation

Answer: C

Rationale:

A) Displacement:

Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply.

B) Reaction formation:

Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.

C) Denial:

Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.

D) Rationalization:

Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.

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A nurse is caring for a client who has received nine electroconvulsive therapy (ECT) treatments and reports short-term memory loss. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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