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.
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The correct answer is A. Clean the wound from the center to the outer edges.
Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.
The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.
Correct Answer is B
Explanation
The correct answer is B. Diminished pulses on the affected extremity indicate impaired circulation, which can lead to tissue ischemia, necrosis, and compartment syndrome if not corrected promptly. This is a life-threatening complication that requires immediate intervention such as loosening or cutting off the cast, elevating the limb, or administering vasodilators. The other findings are not as urgent, although they may indicate other problems such as hematoma, infection, or nerve injury that need further assessment and treatment.
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