A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse’s rationale for this procedure?

Correct Answer: B

Rationale: The correct answer is B: To prevent anoxia due to medication-induced paralysis of respiratory muscles. During electroconvulsive therapy, muscle relaxants are often used to prevent injury during the seizure. These medications can lead to paralysis of respiratory muscles, causing potential anoxia if oxygen is not administered. Providing pure oxygen ensures adequate oxygenation despite muscle paralysis. Incorrect Choices: A: Preventing increased intracranial pressure is not the primary rationale for administering oxygen during ECT. C: Hypotension, bradycardia, and bradypnea are potential side effects of ECT itself, but oxygen administration is not primarily to prevent these. D: Oxygen is not administered to prevent a blocked airway but rather to ensure adequate oxygenation during muscle paralysis.

Correct Answer: D

Rationale: Step-by-step rationale for why choice D is correct: 1. Maslow's hierarchy of needs places self-esteem as a fundamental psychological need. 2. Patient hygiene and dress contribute to self-esteem by promoting a sense of dignity and self-worth. 3. Attending to hygiene and dress before spousal visits shows respect for the patient's self-esteem. 4. This strategy directly addresses the self-esteem needs of elderly patients by enhancing their sense of self-worth and respect. Summary of why other choices are incorrect: A: Providing privacy for spouses does not directly address the patient's self-esteem needs. B: Arranging dining with spouses may enhance social needs but not directly address self-esteem. C: Including patients and spouses in educational sessions may promote social interaction but does not directly target self-esteem needs.

Correct Answer: A

Rationale: The correct answer is A because universality in Yalom's therapeutic factors refers to the recognition that one is not alone in their struggles. Patient A demonstrates this by acknowledging that others also face loneliness, fostering a sense of commonality and reducing feelings of isolation. In contrast, patient B's dysfunctional patterns do not relate to universality. Patient C's sense of belonging is related to group cohesion, not universality. Patient D's anger expression is not directly linked to recognizing shared experiences.

Correct Answer: A

Rationale: The correct answer is A because prescribing antianxiety agents may mask the woman's grief instead of allowing her to process and work through it naturally. This could potentially prolong her grief by avoiding the necessary emotional processing. The other choices, B, C, and D, all involve support that can help the woman cope with her loss in a healthy way. B offers emotional support and companionship, C helps with practical tasks, and D provides assistance in managing practical matters, all of which can facilitate the grieving process rather than prolong it.

Correct Answer: B

Rationale: The correct answer is B: Concrete operational. At this developmental level, children typically exhibit the ability to focus, coordinate, and imagine a series of events. This stage, according to Piaget's theory, usually occurs around ages 7 to 11. Children at this stage can perform logical operations, understand conservation, and think more systematically. A: Preoperational - Children at this stage (ages 2-7) lack the ability to perform logical operations and struggle with understanding conservation and cause-and-effect relationships. C: Formal operational - This stage (typically starting around age 11) involves abstract thinking, hypothetical reasoning, and problem-solving beyond the concrete level. D: Postoperational - This term is not a recognized developmental stage in Piaget's theory.

Correct Answer: D

Rationale: The correct answer is D because research indicates that suicides can occur accidentally as a result of self-injurious behaviors. This is known as an unintentional suicide, where the individual did not intend to die but died due to the severity of their self-injurious behavior. This information is crucial for planning safety interventions for the teenager, as it highlights the potential seriousness of self-injury. Choice A is incorrect because research shows that suicidal ideation is not uncommon among teenagers, so it cannot be assumed that they rarely entertain the idea of suicide. Choice B is also incorrect because while self-injury can be a risk factor for future suicidal attempts, it is not always the case. Choice C is relevant but not the most specific to the scenario presented in the question, as it focuses solely on suicidal ideations rather than the potential accidental outcomes of self-injury.

Correct Answer: C

Rationale: The correct answer is C because the patient who started drinking daily after retirement as a coping mechanism for arthritis has the highest risk for alcohol abuse. This behavior indicates a potential dependence on alcohol to manage physical and emotional discomfort, leading to increased consumption and potential addiction. Choice A is not the correct answer because consuming 1 glass of wine nightly with dinner is generally considered moderate drinking and does not necessarily indicate alcohol abuse. Choice B is also not the correct answer as social drinking throughout adult life, even if justified as a reward, does not inherently suggest alcohol abuse without further evidence of problematic drinking patterns. Choice D is incorrect as the patient has a history of alcohol abuse but currently abstains and seeks support through AA, indicating active efforts to maintain sobriety and reduce the risk of alcohol abuse.

Correct Answer: B

Rationale: The correct answer is B: Medications the patient has recently taken. This is crucial because certain medications can cause delirium in elderly patients. Step 1: Evaluate recent medication history. Step 2: Identify medications known to cause delirium. Step 3: Determine if the patient has taken any of these medications. Other choices are incorrect because: A: Evidence of spasticity or flaccidity is more related to neuromuscular conditions. C: Level of preoccupation with somatic symptoms is not specific to delirium assessment. D: The patient’s level of motor activity is not a key factor in distinguishing delirium from other problems.

Correct Answer: C

Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.