A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?
You will be given an opioid analgesic before the procedure.
Expect to be confused several hours after the procedure.
You cannot eat or drink for 24 hours before the procedure.
A consent form is not required to have this procedure.
The Correct Answer is B
Choice A reason: Opioid analgesics are not typically given before electroconvulsive therapy (ECT). Instead, a general anesthetic and a muscle relaxant are administered to ensure the patient is asleep and to prevent muscle contractions during the procedure. The nurse should inform the client about the medications they will receive before ECT, but opioid analgesics are not usually part of the protocol.
Choice B reason: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.
Choice C reason: Clients are usually instructed to fast (not eat or drink) for a shorter period, typically 6-8 hours, before the procedure to reduce the risk of aspiration during anesthesia. Informing the client to fast for 24 hours is excessive and not in line with standard preoperative fasting guidelines.
Choice D reason: A consent form is required before undergoing ECT. Informed consent is a critical component of the process, ensuring that the client understands the procedure, its benefits, risks, and potential side effects. The nurse must reinforce the importance of obtaining and signing the consent form before proceeding with ECT.
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Correct Answer is B
Explanation
Choice A reason: Response prevention is a technique often used in the treatment of obsessive-compulsive disorder (OCD). This approach involves preventing the client from engaging in the compulsive behavior they typically perform in response to an anxiety-producing obsession. While effective for OCD, this technique is not typically used for treating specific phobias like the fear of elevators.
Choice B reason: Systematic desensitization is an effective behavioral strategy for decreasing anxiety related to specific phobias. This method involves gradually exposing the client to the feared object or situation—in this case, elevators—in a controlled and progressive manner while teaching relaxation techniques. By slowly and systematically confronting the phobia, the client can learn to reduce their anxiety response over time. This approach helps them manage their fear more effectively and builds their confidence in facing the phobic situation.
Choice C reason: Thought stopping is a cognitive-behavioral technique used to interrupt and prevent distressing thoughts. The client is trained to recognize these thoughts and use a specific action or command, such as saying "Stop" out loud, to halt the negative thought process. While this technique can be helpful for managing anxiety and intrusive thoughts, it is not the primary behavioral strategy for treating specific phobias.
Choice D reason: Flooding, also known as exposure therapy, involves exposing the client to the phobic situation in an intense and prolonged manner until their anxiety diminishes. This approach can be effective but is often overwhelming and can cause significant distress. It requires careful supervision and is not typically the first-line treatment for specific phobias due to the potential for causing trauma or exacerbating the fear.
Correct Answer is C
Explanation
Choice A reason: Determining whether the client's goals are met is part of the evaluation phase of the nurse-client relationship. This phase comes after the working phase and focuses on assessing the outcomes of the interventions and the progress made toward achieving the client's goals.
Choice B reason: Collecting data about the client's current health status is typically part of the assessment phase, which occurs at the beginning of the nurse-client relationship. During this phase, the nurse gathers comprehensive information about the client's physical, psychological, and social health to inform the care plan.
Choice C reason: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health. Teaching problem-solving skills helps empower the client to manage their condition effectively.
Choice D reason: Establishing a regular meeting time with the client is part of the orientation phase of the nurse-client relationship. In this initial phase, the nurse and client get to know each other, build rapport, and establish the parameters for the relationship, including setting up regular meetings.
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