A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?

Provide frequent reorientation after ECT.

Schedule follow-up ECT treatments 1 month apart.

Instruct the client to notify the provider if discomfort is felt during ECT.

Initiate NPO status 1 hr prior to ECT.

Answer and Explanation

The Correct Answer is A

The correct answer is A.

Provide frequent reorientation after ECT. The rationale is that ECT can cause temporary memory loss and confusion, which can be distressing for the client. The nurse should help the client recall their name, location, date, and reason for ECT. The nurse should also reassure the client that their memory will improve over time.

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Correct Answer is ["D","E"]

Explanation

Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.

Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.

Other findings:

Urine output 40 mL in the last hour:Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.

Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.

Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.

A. Nursing care plan B. Provider's progress notes C. Controlled substance inventory record D. Incident report

Correct Answer is D

Explanation

The correct answer is D.

Incident report. An incident report is a form that nurses fill out when an error, accident, or injury occurs involving a client, staff, or visitor. The purpose of an incident report is to document the facts, identify the causes, and prevent recurrence of similar incidents. The nurse should document the medication error in an incident report and notify the provider and supervisor as soon as possible.

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A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["D","E"]

Explanation

Other findings:

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is D

Explanation

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