A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?
Provide frequent reorientation after ECT.
Schedule follow-up ECT treatments 1 month apart.
Instruct the client to notify the provider if discomfort is felt during ECT.
Initiate NPO status 1 hr prior to ECT.
The Correct Answer is A
The correct answer is A.
Provide frequent reorientation after ECT. The rationale is that ECT can cause temporary memory loss and confusion, which can be distressing for the client. The nurse should help the client recall their name, location, date, and reason for ECT. The nurse should also reassure the client that their memory will improve over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.
B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.
C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.
D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.
Correct Answer is ["A","D","E"]
Explanation
Urine output: At 1400, the client had oliguria (20 mL/hr). Magnesium is primarily excreted by the kidneys; if urine output is low, magnesium levels can rise to toxic levels. An increase to 40 mL/hr (exceeding the standard minimum threshold of 30 mL/hr) indicates improved renal perfusion and the body's ability to clear the magnesium, reversing the toxicity.
Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.
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