A nurse is caring for a client who is crying after receiving a terminal cancer diagnosis. Which of the following responses should the nurse make?

"I'm going to contact your partner for you now."

"Let's talk about the treatment options you were given.”

"I'll stay with you for a little while if that's okay."

"Your provider will take good care of you."

Answer and Explanation

The Correct Answer is C

Rationale:

A. "I'm going to contact your partner for you now.": While involving loved ones can be supportive, taking action without first addressing the client’s emotional state or asking their preference may feel dismissive or intrusive during a vulnerable moment.

B. "Let's talk about the treatment options you were given.": Shifting the focus to treatment too quickly can invalidate the client's immediate emotional response. Emotional support should take precedence over information processing in the early moments of distress.

C. "I'll stay with you for a little while if that's okay.": Offering presence and emotional support communicates compassion and allows the client space to express grief. This response fosters trust and demonstrates empathy without pressuring the client to talk or act.

D. "Your provider will take good care of you.": Though intended to reassure, this response deflects the client’s emotional pain and may come off as impersonal or minimizing. It does not address the need for immediate emotional support.

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Correct Answer is D

Explanation

Rationale:

A. Tonic-clonic seizures: Tonic-clonic activity is induced during the ECT procedure itself but typically resolves within seconds. It is not expected to persist 15 minutes post-procedure, as seizure activity is carefully controlled and monitored during the treatment.

B. Sleep apnea: While general anesthesia used during ECT can cause brief respiratory depression, sleep apnea is not a typical or expected consequence of the procedure. Continuous monitoring ensures airway patency during and immediately after treatment.

C. Paresthesias: Numbness or tingling sensations (paresthesias) are not common side effects of ECT. The procedure affects brain activity and cognition rather than peripheral nerves, making this symptom unlikely post-treatment.

D. Disorientation: Temporary confusion or disorientation is a common and expected side effect shortly after ECT. It typically resolves within 30 to 60 minutes as the effects of anesthesia wear off, and it is routinely monitored during recovery.

A. Ensure the client swallows each dose of medication. B. Limit the personal toiletries in the client's room to cologne. C. Observe the client's behavior every 2 hr. D. Keep the client's door shut when they are in the room.

Correct Answer is A

Explanation

Rationale:

A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.

B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.

C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.

D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.

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A nurse is caring for a client who is crying after receiving a terminal cancer diagnosis. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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