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: B

Rationale: The correct answer is B: Age-appropriate language development. Asperger's disorder is characterized by normal to above-average language development, whereas autism typically presents with delays or impairments in language skills. This is important for planning care as it influences communication strategies and interventions for individuals with Asperger's. A: Repetitive patterns of behavior are more indicative of autism, not specific to Asperger's. C: Stereotypic movements and speech patterns are also more associated with autism and not a defining feature of Asperger's. D: Obsession with objects that move in a spinning motion is a specific behavior that may be seen in some individuals with autism, but it is not a defining characteristic of Asperger's disorder.

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: 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: A, C

Rationale: The correct answers are A and C. Statement A indicates a positive attitude towards aging, which is a good predictor of positive well-being. Feeling satisfied with growing older can lead to better emotional health and higher perceived mortality. Statement C suggests that retirement provides opportunities for personal fulfillment, which can contribute to positive well-being. Statements B and D do not directly address attitudes towards aging or well-being, making them less reliable predictors.

Correct Answer: C

Rationale: The correct answer is C because reorienting the patient to time, place, and person is crucial in the immediate post-ECT period to help the patient regain orientation as consciousness improves. This intervention helps prevent confusion and disorientation commonly experienced after ECT. A: Continually stimulating the patient may be overwhelming and unnecessary. B: Continuing bagging is not relevant after ECT as the patient's respiratory function should have stabilized. D: Encouraging walking and eating can be unsafe immediately post-ECT due to potential disorientation and muscle weakness.

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: C

Rationale: The correct answer is C because engaging the patient in activities designed to permit success helps boost self-esteem by providing opportunities for achievement. This intervention focuses on building the patient's confidence and self-worth through positive experiences. Choice A is incorrect as it addresses stress relief rather than self-esteem. Choice B is irrelevant as it pertains to hallucinations, not self-esteem. Choice D is also incorrect because while verbalizing feelings is important, it may not directly target the underlying issue of low self-esteem.

Correct Answer: A

Rationale: The correct answer is A because the teen is expressing a fear of losing control over her emotions if she starts crying. This is evident from her belief that she will never stop crying once she starts. Option B (Losing the support of her friends and family) is incorrect as the statement does not suggest concern about losing support. Option C (Embarrassing herself by crying in public) is incorrect as the fear expressed is more about not being able to stop crying rather than embarrassment. Option D (Appearing emotionally immature) is incorrect as there is no indication that the teen is worried about how others perceive her emotional maturity.