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

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Nurse in Psychiatry Test Bank Questions

Question 1 of 5

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.

Question 2 of 5

Planning safety interventions for a teenager with a history of self-injurious behavior is based on what research-based information?

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.

Question 3 of 5

When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?

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.

Question 4 of 5

A new nurse asks, “My elderly patient has Lewy body disease. What should I do about assessing for pain?” Select the best response from the nurse manager.

Correct Answer: C

Rationale: The correct answer is C because Lewy body disease can affect a patient's ability to communicate pain, making specialized pain assessment tools crucial. Special scales designed for patients with dementia can help in accurately assessing pain levels. These tools consider non-verbal cues and behavioral changes that may indicate pain. Asking the patient's family (A) may not always provide an accurate assessment of pain perception. Using a visual analog scale (B) may be challenging for a patient with cognitive impairment. Focusing solely on mental status (D) may overlook important indicators of pain in patients with Lewy body disease.

Question 5 of 5

A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who:

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.

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