A patient is preparing to receive electroconvulsive therapy. The nurse caring for this patient identifies which patient problem as the highest priority?
Anxiety related to uncertainty of the events of the test
Deficient knowledge related to lack of information regarding the procedure
Disturbed thought process related to confusion
Disturbed thought process related to temporary memory loss
The Correct Answer is A
A. Anxiety related to uncertainty of the events of the test: Addressing the patient's anxiety and providing information about the procedure can help reduce fear and improve cooperation.
B. Deficient knowledge related to lack of information regarding the procedure: While providing information is important, the immediate emotional response (anxiety) takes priority as it can impact the patient's experience of the procedure.
C. Disturbed thought process related to confusion: While disturbed thought processes are relevant, they are not the primary concern pre-procedure.
D. Disturbed thought process related to temporary memory loss: Temporary memory loss can occur post-ECT, but addressing pre-procedure anxiety is a more immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Take her blood pressure twice a day to check for hypertension. Lithium does not typically cause hypertension. Monitoring blood pressure is not a primary concern for patients on lithium.
B. Have her drug blood level checked every month. Regular monitoring of lithium blood levels is crucial to ensure therapeutic levels and avoid toxicity. Lithium has a narrow therapeutic window, and frequent monitoring helps in adjusting the dose to maintain safe and effective levels.
C. Avoid aged cheese and red wine. This advice is relevant for patients taking MAOIs, not lithium. There is no need for patients on lithium to avoid these foods specifically.
D. Examine her skin closely for eruptions. While skin eruptions can be a side effect of some medications, it is not a primary concern for patients on lithium. The focus should be on monitoring for signs of lithium toxicity and other common side effects like tremors, thyroid dysfunction, and renal impairment.
Correct Answer is C
Explanation
A. Fever: Fever can cause weakness or dizziness, but it is not a sudden cause of falling when getting up.
B. A decrease in venous return can contribute to orthostatic hypotension but is not a direct cause on its own.
C. Orthostatic hypotension is a common cause of sudden falls in older adults when they change positions, leading to dizziness or fainting.
D. Dehydration can lead to orthostatic hypotension but is not as direct a cause of sudden falls when getting up as orthostatic hypotension itself.
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