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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. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.

B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.

C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.

D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.

A. Administer oxygen at 2 L/min. B. Encourage coughing and deep breathing. C. Raise the head of the bed. D. Administer prescribed analgesic medication.

Correct Answer is C

Explanation

A. Administer oxygen at 2 L/min.: Oxygen is necessary, but raising the head of the bed first can improve oxygenation more effectively and quickly.

B. Encourage coughing and deep breathing.: While effective, this should be done after positioning the patient appropriately to optimize oxygenation.

C. Raise the head of the bed.: The priority intervention for low oxygen saturation is to improve ventilation and perfusion by raising the head of the bed. This enhances lung expansion, making it easier for the patient to breathe.

D. Administer prescribed analgesic medication.: Pain management is important, but it is not the priority when oxygen levels are dangerously low.

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

Nursing Test Bank

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