A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?
Orient the client and offer reassurance
Encourage the client to drink some fluids
Orient the client and monitor vital signs
Assist the client from the stretcher to a wheelchair
The Correct Answer is C
C. After ECT, the client may be disoriented, confused, or drowsy due to the effects of anesthesia and the procedure itself. Orienting the client to their surroundings and situation helps promote their safety and comfort. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial to assess the client's immediate post-procedural status and detect any complications.
A. Offering reassurance can help alleviate any anxiety or confusion the client may experience. However, while this intervention is important, it may not be the first priority immediately upon admission to the Post Anesthesia Care Unit (PACU).
B. Hydration is important after any medical procedure, including ECT. However, immediately after ECT, the client may still be recovering from anesthesia and may not be fully alert or able to safely drink fluids.
D. Assisting the client with mobility is important but it may not be the first intervention performed in the PACU after ECT. The priority immediately upon admission to the PACU is to ensure the client's safety.
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Related Questions
Correct Answer is C
Explanation
C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.
Correct Answer is D
Explanation
D. This response is consistent with the characteristics of antisocial personality disorder, which include a lack of remorse, as well as a tendency to rationalize behavior or blame others. Individuals with this disorder often fail to accept responsibility for their actions and may exhibit behaviors that are impulsive, reckless, and violate the rights of others without feeling guilty.
A. Individuals with antisocial personality disorder often lack remorse or empathy for the consequences of their actions and may not experience feelings of shame or guilt, even when their behavior results in harm to others.
B. Expressing genuine remorse or empathy for the harm caused to others is uncommon in individuals with antisocial personality disorder.
C. Claiming to have no memory of the behavior or the events leading up to it is a common defense mechanism used. This may serve to avoid accountability or responsibility for their actions, rather than indicating genuine memory impairment. However, it is not characteristic for antisocial personality disorder.
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