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 C

Explanation

Involuntary commitment is a legal process where an individual is admitted to a psychiatric facility against their will due to a perceived risk of harm to themselves or others. The primary concern in involuntary commitment is the safety and well-being of the individual and those around them.

Therefore, it is important for the nurse to inform the client's family about the reason for the involuntary commitment, emphasizing that the client's behavior poses a threat to themselves or others.

incorrect:

A. "A psychiatrist determines that the client's behavior is irrational." This statement focuses on the client's behavior being irrational, which is not the primary criteria for involuntary commitment. It is more important to emphasize the potential harm the client may cause to themselves or others.

B. "The client is unable to manage the affairs necessary for daily life." While this may be a factor contributing to the need for psychiatric treatment, it is not the specific reason for involuntary commitment. The main concern is the risk of harm associated with the client's behavior.

D. "The client has been accused of breaking the law." Involuntary commitment is not based on accusations of breaking the law. It is primarily focused on the safety and well-being of the individual and the potential risk they pose to themselves or others.

A. "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior." B. "I'm curious as to why you are behaving this way. Can you please explain it to me?" C. "I'm very flattered, but I am married and cannot engage in this behavior." D. "I am going to leave now and I'll return in one hour to spend time with you then."

Correct Answer is D

Explanation

The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.

A- "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.

B- "I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.

C- "I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.

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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

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Correct Answer is D

Explanation

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