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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Educating the patient on the surgical process. Preoperative education is important, but ensuring that all essential preoperative requirements are met takes precedence.
B. Ensuring the patient's preoperative checklist is complete. The preoperative checklist ensures that all necessary steps (e.g., consent, lab results, NPO status) are completed before surgery. Missing an essential step could delay or complicate the procedure.
C. Answering all questions for the patient about surgery. Answering questions is important but is not the priority over ensuring surgical readiness.
D. Admitting the patient to the facility. While admission is necessary, it does not take precedence over ensuring all preoperative preparations are complete.
Correct Answer is C
Explanation
A. HCO3- 30 mEq/L: In chronic respiratory acidosis, the kidneys compensate by increasing bicarbonate (HCO3-) to buffer excess CO2.
B. Potassium 3.3 mEq/L: Respiratory acidosis is typically associated with hyperkalemia (high potassium), not hypokalemia (low potassium).
C. PaCO2 50 mm Hg: Respiratory acidosis is caused by CO2 retention, leading to an elevated PaCO2 (>45 mm Hg).
D. pH 7.45: A pH of 7.45 is normal or slightly alkalotic. Respiratory acidosis is characterized by a pH below 7.35.
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