The nurse is reviewing the client's medical record.

The nurse is assisting with the care the client prior to a blood transfusion

Which of the following actions should the nurse take? Select all that apply.

A) Tonic-clonic seizures: Tonic-clonic seizures are typically the result of a seizure disorder, but during electroconvulsive therapy (ECT), a controlled seizure is intentionally induced to facilitate the therapeutic effects. After the procedure, there should not be uncontrolled tonic-clonic seizures. The goal is to induce a seizure under controlled conditions during the procedure itself, so this is not an expected finding 15 minutes post-ECT.

B) Paresthesias: Paresthesias (tingling or numbness) are not a common immediate side effect following ECT. While ECT can have some neurological effects, paresthesias are more commonly associated with other neurological conditions or nerve injuries, rather than as a direct result of the procedure itself.

C) Sleep apnea: Sleep apnea is not a typical immediate consequence of ECT. While ECT can have a range of physical and psychological side effects, sleep apnea, which involves breathing interruptions during sleep, is not an expected finding following the procedure.

D) Disorientation: Disorientation is a common and expected finding following ECT. It typically occurs due to the temporary effects of anesthesia, the brain’s response to the electrical stimulation, and the stress of the procedure. Clients often experience confusion, memory loss, and disorientation for a short period, particularly in the first 15 minutes after the procedure, as the anesthesia wears off and they recover from the induced seizure. This is a normal part of the recovery process.

A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.