Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Sexual behaviors

Frequency of hospitalizations

Sodium level

Hepatitis Viral Study (HAA) results

Answer and Explanation

Correct Answer : C,D

Choice C rationale:

Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.

Rationale for Immediate

Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.

Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.

Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.

Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.

Choice D rationale:

Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.

Rationale for Immediate

Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).

Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.

Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.

Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.

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Correct Answer is D

Explanation

A rationale:

Incorrect. While patients typically do sleep for a period after ECT, the duration is usually shorter, around 30-60 minutes.

Providing inaccurate information about the length of sleep can lead to confusion and anxiety for the patient.

Evidence: Studies have shown that the average recovery time following ECT is around 30-60 minutes, with most patients feeling alert and oriented within that time frame. (Source: NIH.gov) Choice B rationale:

Incorrect. While ECT can be highly effective in treating depression, it is not considered a cure. It's important to manage expectations and emphasize that ECT is a treatment option that can significantly improve symptoms but may not guarantee a complete cure.

Evidence: Research indicates that ECT has a remission rate of approximately 50-70% in patients with severe depression, meaning that many patients experience a significant reduction or disappearance of symptoms. However, relapse rates can range from 30-50%, indicating that ongoing maintenance treatment is often necessary. (Source: American Psychiatric Association)

Choice C rationale:

Incorrect. Muscle relaxants, not seizure-preventing medications, are administered during ECT to protect the patient from injury during the induced seizure. It's crucial to clarify this distinction to avoid misunderstandings about the procedure's mechanism of action.

Evidence: Standard ECT protocols involve the use of a short-acting muscle relaxant, such as succinylcholine, to prevent muscle contractions during the seizure. This helps to minimize the risk of physical injury and ensure patient safety. (Source: Healthline.com)

Choice D rationale:

Correct. Temporary memory loss is a common side effect of ECT, and it's essential to inform patients about this potential issue to prepare them for the experience and address any concerns they may have.

Evidence: Studies have shown that approximately 40-50% of patients experience some degree of memory impairment following ECT, primarily affecting short-term memory of events occurring around the time of treatment. However, this memory loss is usually temporary and resolves within a few weeks or months for most patients. (Source: Studocu.com)

A. “I know you hear the voices, but I do not.” B. “How often do you hear the voices?” C. “What are the voices telling you?” D. “The voices are part of your illness.”

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.

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Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning. The nurse has reviewed the client’s electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Nursing Test Bank

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A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

Correct Answer is C

Explanation

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Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)