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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
A. Breast cancer: Breast cancer itself does not cause metabolic acidosis. However, in rare cases, tumor lysis syndrome from aggressive cancer treatment can lead to metabolic acidosis due to increased release of intracellular acids.
B. Parathyroidectomy: Removal of the parathyroid glands can cause hypocalcemia, but it does not directly lead to metabolic acidosis.
C. Use of salicylates: Salicylate toxicity (aspirin overdose) can cause metabolic acidosis due to the accumulation of lactic acid and ketoacids.
D. Rhabdomyolysis: Rhabdomyolysis causes metabolic acidosis due to the breakdown of muscle tissue, leading to the release of myoglobin, potassium, and acids into the bloodstream.
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