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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. Numbness of fingers. Numbness or tingling (paresthesia) is more common in respiratory alkalosis due to low CO₂ levels causing calcium binding changes.

B. Dry skin. Respiratory acidosis does not typically cause dry skin; rather, it may cause cyanosis or flushed skin due to CO₂ retention.

C. Abdominal pain. Abdominal pain is more commonly seen in metabolic acidosis, not respiratory acidosis.

D. Lethargy. Respiratory acidosis leads to CO₂ retention, which depresses the central nervous system, causing lethargy, confusion, and even coma in severe cases.

A. Oxygen saturation 96% B. Blood pH 7.32 C. Hemoglobin level 12 mg/dL D. PaO2 80 mm Hg

Correct Answer is B

Explanation

A. Oxygen saturation 96%. This is a normal oxygen saturation level, so it is not a concern.

B. Blood pH 7.32. A pH below 7.35 indicates acidosis, which is concerning in a patient with a respiratory disorder, as it may indicate respiratory failure.

C. Hemoglobin level 12 mg/dL. This is a normal hemoglobin level for most adults and does not indicate a critical problem.

D. PaO2 80 mm Hg. While slightly lower than the normal range (normal is 80–100 mm Hg), this is not the most concerning finding.

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

Nursing Test Bank

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