A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?
Administer phenytoin 30 min prior to the procedure
Instruct the client to expect a headache following the procedure
Monitor the client's cardiac rhythm during the procedure
Place the client in four-point restraints prior to the procedure
The Correct Answer is C
Choice A reason: Phenytoin, an anticonvulsant, is not routinely given before ECT, as the procedure induces controlled seizures to stimulate brain activity, treating depression via neurochemical changes. Administering phenytoin would inhibit seizure activity, reducing ECT efficacy by blocking neuronal excitability, making this an inappropriate action for the procedure.
Choice B reason: Instructing about post-ECT headaches is valid, as they result from cerebral vasoconstriction or muscle tension during seizures. However, this is a post-procedure expectation, not a priority action during planning. Monitoring cardiac rhythm takes precedence, as ECT’s autonomic stimulation poses immediate cardiovascular risks requiring real-time management.
Choice C reason: Monitoring cardiac rhythm during ECT is critical, as the procedure induces seizures that stimulate the autonomic nervous system, causing transient tachycardia or arrhythmias due to catecholamine surges. These can exacerbate underlying cardiac conditions, risking instability. Continuous monitoring ensures early detection and management of cardiovascular complications, prioritizing patient safety.
Choice D reason: Four-point restraints are not used in ECT, as patients are under general anesthesia, preventing movement. Restraints risk injury and are unnecessary, as muscle relaxants like succinylcholine minimize convulsive movements. This approach contradicts ECT’s controlled, anesthetized protocol, making it inappropriate for ensuring safety during the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Tylenol with Codeine (acetaminophen and codeine) in tablet form (1T) typically refers to a standard dose, but in liquid form, the concentration varies. Assuming a common elixir (120 mg acetaminophen/12 mg codeine per 5 mL), 15 mL delivers the standard dose. 15.5 mL slightly exceeds this, risking overdose and potential hepatotoxicity from acetaminophen, making it incorrect.
Choice B reason: Tylenol with Codeine elixir is commonly 120 mg acetaminophen and 12 mg codeine per 5 mL. One tablet equivalent (1T) typically corresponds to 15 mL, delivering 360 mg acetaminophen and 36 mg codeine, aligning with standard dosing for pain relief. This volume ensures therapeutic efficacy without exceeding safe limits, matching pharmacological guidelines.
Choice C reason: A 40 mL dose of Tylenol with Codeine elixir (120 mg acetaminophen/12 mg codeine per 5 mL) would deliver 960 mg acetaminophen and 96 mg codeine, far exceeding safe single-dose limits. This risks acetaminophen-induced liver toxicity and opioid-related respiratory depression, as it disrupts the therapeutic window, making this choice scientifically inappropriate.
Choice D reason: A 30 mL dose of Tylenol with Codeine elixir (120 mg acetaminophen/12 mg codeine per 5 mL) provides 720 mg acetaminophen and 72 mg codeine, doubling a typical single dose. This excessive amount increases the risk of hepatotoxicity and opioid side effects like sedation or respiratory depression, rendering it unsuitable for standard administration.
Correct Answer is B
Explanation
Choice A reason: Mutism, the absence of speech, is not typical in acute mania, where dopamine-driven hyperactivity increases verbal output. Mutism is more associated with catatonia or severe depression, where psychomotor inhibition or serotonin deficits reduce communication, making this inconsistent with mania’s neurobiological profile.
Choice B reason: Flight of ideas, characterized by rapid, disjointed speech, typifies acute mania due to dopamine and norepinephrine hyperactivity in the prefrontal cortex and limbic system. This leads to accelerated thought processes and pressured speech, reflecting the manic state’s heightened neural excitability and reduced inhibitory control.
Choice C reason: Hesitant speech is not characteristic of acute mania, where dopamine-driven hyperactivity results in rapid, pressured speech. Hesitancy may occur in anxiety or depression, linked to serotonin dysregulation or prefrontal inhibition, contrasting with mania’s uninhibited, accelerated verbal output driven by neurochemical overstimulation.
Choice D reason: Psychomotor retardation, slowed speech and movement, is typical of depression, driven by serotonin and dopamine deficits. In acute mania, heightened dopamine and norepinephrine activity cause rapid speech and agitation, making psychomotor retardation incompatible with the neurobiological profile of manic speech patterns.
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