The nurse is collecting data from the client following the transfusion of 2 units of packed RBCs.

Exhibits

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Laboratory Results:

1800:

WBC count 6,700/mm (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs:

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Temperature 37.5°  C (99.5°  F)

O2 saturation 100% 2 L/min O2 via nasal cannula

Assessment:

1800:

Physical Exam

General: no distress

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding

Neurologic: awake and alert

A. Neck pain can occur in some patients following electroconvulsive therapy (ECT) due to muscle tension or positioning during the procedure. However, it is not a common or expected adverse reaction associated with ECT, so it is not the primary concern to address.
B. Temporary memory loss is a well-documented adverse reaction following ECT. Patients may experience difficulties with short-term memory, particularly related to events that occurred around the time of the treatment. This memory loss is usually temporary, but it can be distressing for some individuals.
C. Voice alteration is not typically associated with ECT. Although some patients may experience hoarseness or changes in vocal quality due to intubation or anesthesia, this is not a direct result of ECT itself and is not commonly mentioned in the context of ECT side effects.
D. Tingling of the scalp is not a recognized adverse reaction to ECT. Patients may experience various sensations, but tingling is not a common or documented response. The primary focus should be on more significant effects, such as temporary memory loss and potential confusion immediately following the treatment.

A. Position the client's head northward. In Islamic tradition, the body is typically positioned with the head facing Mecca, not northward. This direction holds religious significance for Muslims as the holiest city in Islam.
B. Allow a family member to stay with the client's body for 8 hr. While family members may wish to remain with the body, there is no strict time limit. Islamic customs often encourage continuous presence until burial, which should occur as soon as possible.
C. Position the client's head toward Mecca. While this is an important aspect of Islamic postmortem care, the entire body, not just the head, should be positioned so that it faces Mecca if possible. Additionally, proper washing and shrouding rituals are observed before burial.
D. Allow a family member of the client to stay with the client's body until burial. In Islamic tradition, the body is never left alone, and family members or members of the Muslim community often stay with the deceased until burial. This practice ensures that religious rites are observed and that the body is treated with the utmost respect.