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

Answer and Explanation

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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Correct Answer is C

Explanation

C. This approach involves establishing clear and consistent rules and boundaries, which are crucial for managing antisocial behaviors. It helps to create a structured environment where the consequences of actions are predictable and reinforces the understanding of acceptable behaviors.
A. Encouraging the client to explore and address underlying emotions, including feelings of fear and inferiority, can be an important aspect of therapy and may help mitigate manipulative behaviors over time.
B. Antisocial personality disorder is associated with behaviors that violate social norms and the rights of others. Positive reinforcement for these behaviors would not address the underlying issues and may inadvertently reinforce harmful patterns of behavior.
D. Ignoring inappropriate behavior may reinforce the notion that manipulation is an effective means of achieving desired outcomes and may lead to further boundary violations.

A. client may have decided to carry out the suicide plan. B. medication has potentiated serotonin syndrome. C. medication dosage should be decreased. D. client's behavioral change is normal and expected.

Correct Answer is D

Explanation

D. This recognizes that the client's improvement in mood is a typical response to antidepressant medication and does not automatically suggest any negative outcomes such as suicidal ideation or serotonin syndrome.
A. It's important to be vigilant for signs of suicidal ideation but sudden improvements in mood can also occur as a positive response to antidepressant medication.
B. The client's description of feeling better does not align with the symptoms of serotonin syndrome, which include agitation, confusion, rapid heart rate, high blood pressure, and hyperthermia.
C. Antidepressant medications often take several weeks to reach their full therapeutic effect, so it's not unusual for some clients to experience an improvement in mood within the first few weeks of treatment.

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A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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