A nurse is reinforcing teaching with a client whose provider has prescribed
electroconvulsive therapy (ECT). Which of the following information should
... [Show More] the
nurse include?
a. The client will receive continuous oxygen during the electrical stimulation
intervals. Incorrect
(The client will receive oxygen throughout the procedure. However, the oxygen
will be removed during the brief electrical stimulation intervals.)
b. A benzodiazepine will be administered prior to the procedure. Incorrect (A
benzodiazepine should not be administered because it interferes with the seizure
process. A short-acting anesthetic, such as propofol, will be administered.)
c. ECT is an option for clients after medication has been unsuccessful.
d. Confusion is expected for the first 2 days after treatment. (Clients who receive
ECT can have confusion and disorientation for several hours after treatment.)
- C. ECT is an option for clients after medication has been unsuccessful.
(Medication is the first-line of treatment for depression. ECT is prescribed when
medication has been unsuccessful.)
A nurse is assisting with discharge planning for a client who needs to attend a day
treatment center ad has limited community and financial support. Which of the
following referrals should the nurse recommend including in the client's discharge
plan?
A. Social worker
B. Recreational therapist(Although recreational therapists can promote therapies,
such as art and music, to help enhance and preserve mental health, they do not
usually address issues regarding financial support and community resources.)
C. Psychologist (Although psychologists can provide individual or family therapy
for clients, they do not usually address issues regarding financial support and
community resources.)
D. Pharmacist (Pharmacists prepare prescribed medications and dispense
medications in acute care and community settings. They coordinate with the
provider and nurses regarding the client's medication regime. However, they do not
address issues regarding financial support and community resources.) - A. Social
worker (Social workers can assist clients with building a support structure to help
promote and preserve mental health, including contacting day treatment centers
and arranging for financial and other community resources.)A nurse is developing countertransference toward a client during the working
phase of the nurse-client relationship. To correct the situation, which of the
following actions should the nurse take?
A. Tell the client how to change their behaviors. (This action places responsibility
on the client to correct the situation. When dealing with countertransference, it is
the nurse's responsibility to find an appropriate solution.)
B. Talk to the client about the developing feelings. (The nurse should avoid
disclosing personal feelings because these feelings can interfere with the nurseclient relationship. When dealing with countertransference, it is the nurse's
responsibility to find an appropriate solution, not the client's.)
C. Ask to be reassigned to a different client. (In order to achieve personal and
professional growth, the nurse should work through the issue of
countertransference by caring for this client, rather than asking for a new
assignment.)
D. identify personal response to the client. - D. identify personal response to the
client.
(Countertransference is an emotional response toward the client by the nurse. This
response might be related to the nurse's past unresolved feelings or relationships.
These feelings can interfere with the nurse-client therapeutic relationship. In order
to correct the situation of countertransference, the nurse must recognize personal
reactions to the client in an attempt to work through these feelings.)
A nurse is collecting data from a client who has bipolar and a history of mania.
Which of the following findings should the nurse identify as an indication that the
client is relapsing?
A. Weight gain (Weight loss, rather than weight gain, can indicate relapse in a
client who has a history of mania.)
B. Pressured speech
C. Ritualistic behavior (Ritualistic behavior is an indication of obsessivecompulsive disorder, not mania.)
D. Anhedonia (Anhedonia is a negative symptom of schizophrenia. Anhedonia is
defined as a loss of interest in daily activities and the inability or lack of capacity
to experience pleasure in general. This is not an indication of relapse in a client
who has a history of mania.) - B. Pressured speech (The nurse should identify that
rapid or pressured speech, provocative behavior, and insomnia are indications of
potential relapse in a client who has bipolar disorder and a history of mania.)
History and Physical
Subjective: Client states, "My stomach hurts."; "I feel sadder and more alone every
day."Client's adult child stated to the nurse upon dropping the client off today, "I've
been meaning to tell you, I started giving my dad St. John's wort several weeks ago
to improve his mood."
Objective: Episodes of speech incoherency, rapid mood swings, 3 episodes of
vomiting in the past 40 min
Moderate Alzheimer's disease.
Provider Prescriptions
Fluoxetine 20 mg PO daily
Trazodone 50 mg PO daily at bedtime
Omeprazole 20 mg PO daily
Diagnostic Results
Blood pressure 172/94 mm Hg
Temperature 38.2° C (100.8° F)
Pulse rate 110/min
Respiratory rate 24/min
A nurse is caring for a client in a day treatment program. Which of the following
actions should the nurse take? (Click on the exhibit tabs for additional information
about the client. There are three tabs that contain separate categories of data)
A. Request transport for the client to an emergency department.
B. Place a hypothermia blanket on the client. (There is no indication that a
hypothermia blanket is necessary for this client.)
C. Discontinue the client's fluoxetine therapy immediately. (Fluoxetine should not
be discontinued abruptly because this can cause the client to exhibit manifestations
of withdrawal.)
D. Implement droplet precautions for the client. (There is no indication for the
implementation of droplet precautions for this client. Droplet precautions are used
for clients who have diseases that are transmitted by large droplets that are
expelled into the air.) - A. Request transport for the client to an emergency
department. (The nurse should request transport for the client to the nearest
emergency department because the client has manifestations of serotonin
syndrome. Serotonin syndrome is a life-threatening syndrome and is caused by an
over activation of the central serotonin receptors. This is related to interactions
with taking an SSRI and trazodone along with St. John's wort. Manifestations of
serotonin syndrome include hypertension, tachycardia, vomiting, abdominal pain,
and mental status changes.) [Show Less]