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Which of the following nursing diagnosis take priority immediately after electroconvulsive therapy (ECT)

Chronic confusion r/t ECT treatment

Activity intolerance r/t weakness

Impaired social interaction r/t confusion

Risk for injury r/t altered mental status

Answer and Explanation

The Correct Answer is D

A. Chronic confusion r/t ECT treatment. Memory impairment may occur but is not the immediate priority.

B. Activity intolerance r/t weakness. Weakness can occur but is not the most urgent concern post-ECT.

C. Impaired social interaction r/t confusion. Social interaction is a lower priority compared to physical safety.

D. Risk for injury r/t altered mental status. Post-ECT, clients may be confused or disoriented, increasing their risk of falls or injury. Ensuring safety is the top priority.

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Correct Answer is D

Explanation

A. Bipolar disorder: Bipolar disorder involves episodes of mania and depression but does not typically present with postpartum psychotic symptoms such as hallucinations.

B. Premenstrual dysphoric disorder: This is a severe form of premenstrual syndrome (PMS) that affects mood, but it is not associated with postpartum psychosis or auditory hallucinations.

C. Psychotic depression: Psychotic depression can include hallucinations, but in a postpartum context, postpartum psychosis is the more likely diagnosis.

D. Postpartum depression: Severe postpartum depression can lead to postpartum psychosis, which includes symptoms like hallucinations and delusions. This is a medical emergency requiring immediate intervention.

A. A client who is taking a thiazide diuretic B. A client who has salicylate intoxication C. A client who has diarrhea D. A client who is vomiting

Correct Answer is C

Explanation

A. A client who is taking a thiazide diuretic: Thiazide diuretics promote loss of potassium and hydrogen ions, leading to metabolic alkalosis rather than acidosis.

B. A client who has salicylate intoxication: Early salicylate toxicity causes respiratory alkalosis, though severe cases can progress to metabolic acidosis.

C. A client who has diarrhea: Chronic diarrhea leads to excessive bicarbonate loss, resulting in metabolic acidosis.

D. A client who is vomiting: Vomiting leads to loss of stomach acid (HCl), which causes metabolic alkalosis, not acidosis.

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Which of the following nursing diagnosis take priority immediately after electroconvulsive therapy (ECT)

Nursing Test Bank

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