A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
Sleep apnea
Disorientation
Tonic-clonic seizures
Paresthesias
The Correct Answer is B
Disorientation is a common side effect of ECT and is typically temporary. It may include confusion and difficulty recalling recent events or personal information. This post-treatment disorientation is often referred to as the "postictal state" and usually resolves within a short period of time.
Sleep apnea, tonic-clonic seizures, and paresthesias are not expected findings following ECT and would require immediate attention and intervention if they were to occur. It is important for the nurse to closely monitor the client's vital signs, oxygen saturation levels, and neurological status after the procedure to ensure their safety and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Having the baby latch on to both the nipple and areola during breastfeeding is essential for effective milk transfer and optimal breastfeeding. The baby should take in a good portion of the areola along with the nipple to ensure a proper latch and a comfortable feeding experience for both the mother and the baby. This allows the baby to obtain enough milk and stimulates milk production in the mother.
Let's briefly discuss the other statements:
A- "My baby should breastfeed 5 to 10 minutes on each breast": The duration of breastfeeding can vary from baby to baby, but it is generally recommended to allow the baby to breastfeed until they are satisfied and have emptied one breast before switching to the other breast. This ensures that the baby receives both the foremilk and the hindmilk, which are important for adequate nutrition.
B- "I should not wake my baby during the night to breastfeed": In the early days after birth, it is important to establish frequent and regular breastfeeding to support milk production and ensure the baby receives enough nourishment. Newborns typically need to breastfeed at least 8 to 12 times in 24 hours, including during the night. If the baby is sleeping for a long period, it may be necessary to wake them for feeding to ensure proper nutrition and hydration.
C- "I should keep my baby on a strict feeding schedule": Breastfeeding should be based on the baby's cues and demand rather than a strict schedule. Newborns should be breastfed whenever they show hunger signs, such as rooting, sucking motions, or increased alertness. This helps establish a good milk supply and allows the baby to feed according to their individual needs.

Correct Answer is E
Explanation
Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.
The other options are not appropriate based on the information provided:
- "Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
- "Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
- "Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
- "Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.
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