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.)

Choice A rationale:

Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.

Choice B rationale:

Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.

Choice D rationale:

Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.

Choice C rationale:

Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:

Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.

Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.

Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.

Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.

Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.

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)