A patient is preparing to receive electroconvulsive therapy. The nurse caring for this patient identifies which patient problem as the highest priority?

Anxiety related to uncertainty of the events of the test

Deficient knowledge related to lack of information regarding the procedure

Disturbed thought process related to confusion

Disturbed thought process related to temporary memory loss

Answer and Explanation

The Correct Answer is A

A. Anxiety related to uncertainty of the events of the test: Addressing the patient's anxiety and providing information about the procedure can help reduce fear and improve cooperation.
B. Deficient knowledge related to lack of information regarding the procedure: While providing information is important, the immediate emotional response (anxiety) takes priority as it can impact the patient's experience of the procedure.
C. Disturbed thought process related to confusion: While disturbed thought processes are relevant, they are not the primary concern pre-procedure.
D. Disturbed thought process related to temporary memory loss: Temporary memory loss can occur post-ECT, but addressing pre-procedure anxiety is a more immediate priority.

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Correct Answer is F

Explanation

A. Insert nasogastric tube: A nasogastric tube may be inserted early to prevent aspiration and manage gastric distension.
B. Initiate fluid therapy: Fluid therapy is crucial and initiated early to combat hypovolemic shock.
C. Insert Foley catheter: A Foley catheter is often inserted early to monitor urine output and assess renal function.
D. Establish airway: Establishing an airway is the highest priority intervention for burn victims, especially if there are signs of inhalation injury.
E. Administer analgesics: Pain management is crucial but is initiated early in the treatment process.
F. Tetanus prophylaxis: Tetanus prophylaxis is important to prevent infection but is typically administered after the immediate life-threatening issues have been addressed.

A. Transport victim to hospital. B. Stop, drop, and roll. C. Cover victim with clean cloth or sheet. D. Remove all nonadherent clothing and jewelry.

Correct Answer is B

Explanation

A. Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.

B. Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.

C. Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.

D. Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.

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A patient is preparing to receive electroconvulsive therapy. The nurse caring for this patient identifies which patient problem as the highest priority?

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What is the last intervention for a hospitalized severely burned victim during the emergent phase?

Correct Answer is F

Explanation

The nurse arrives to the scene of a house fire. A victim is running out of the house, with flames on the arms. Which is the nurse's first action?

Correct Answer is B

Explanation

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