A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?

Aspiration

Decreased heart rate

Elevated blood pressure

Muscle distress

Answer and Explanation

The Correct Answer is D

A. Aspiration: Succinylcholine is used during electroconvulsive therapy (ECT) to induce muscle relaxation, but it does not specifically prevent aspiration. Aspiration risk is generally minimized by using an endotracheal tube and appropriate airway management during the procedure, not just succinylcholine.
B. Decreased heart rate: Succinylcholine is not used to manage heart rate. While ECT can cause heart rate fluctuations, other medications, like atropine, are typically used if bradycardia is a concern.
C. Elevated blood pressure: Succinylcholine does not address blood pressure regulation. ECT can cause temporary increases in blood pressure, but succinylcholine is used to relax muscles and does not manage blood pressure.
D. Muscle distress: Succinylcholine is given during ECT to relax muscles and prevent muscle contractions or "muscle distress" during the procedure. Without muscle relaxation, muscle contractions during the procedure could cause injury or severe discomfort.

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Correct Answer is D

Explanation

A. Assign the client to a different caregiver each shift: This is not ideal for a client with acute delirium. Consistency in caregivers is important to reduce confusion and help the client feel more secure in a familiar environment.

B. Teach the client assertive techniques: Assertiveness training is more appropriate for clients with anxiety or communication difficulties, not for those with acute delirium. In delirium, the priority is managing cognitive function and safety.

C. Refute the client's perception of visual hallucinations: Refuting hallucinations can cause frustration and worsen the client's confusion. It’s better to acknowledge the hallucinations calmly without validating them, offering reassurance instead of confrontation.

D. Reinforce the client's orientation with a calendar: This is an appropriate intervention. Using a calendar, clock, and other orientation tools helps reinforce reality and can reduce confusion in clients with delirium, aiding in their cognitive stabilization.

A. Request that security guards restrain the client B. Speak to the client in a loud voice. C. Stand directly in front of the client. D. Talk to the client using short, simple sentences. E. Identify the client's stressors

Correct Answer is ["D","E"]

Explanation

A. Request that security guards restrain the client: This should be a last resort. Restraints can escalate a situation and should only be used when necessary for safety. The nurse should attempt to de-escalate the situation first before involving security.

B. Speak to the client in a loud voice: Speaking loudly can escalate the situation, especially with someone who is already agitated. A calm, composed tone is more effective in de-escalating anxiety and aggression.

C. Stand directly in front of the client: Standing directly in front of the client can be perceived as confrontational and could increase the client's aggression. It's better to maintain a safe distance and stand at an angle, not directly in front of them.

D. Talk to the client using short, simple sentences: This is an appropriate response. When a client is agitated, they may have difficulty processing complex information. Using short, clear sentences can help them better understand and respond.

E. Identify the client's stressors: Understanding the client’s stressors helps the nurse address the root cause of the agitation and provides an opportunity to offer support or alternative coping strategies.

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A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute delirium. Which of the following instructions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply).

Correct Answer is ["D","E"]

Explanation

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