Immediately after electroconvulsive therapy, in which position should a nurse place the client?

Correct Answer: A

Rationale: In the context of post-electroconvulsive therapy (ECT), it is crucial for the nurse to place the client on his or her side (Option A) to prevent aspiration. As ECT can induce confusion, disorientation, and muscle weakness immediately after the procedure, there is a risk of regurgitation and aspiration if the client is lying flat on their back. Placing the client on their side helps to ensure that any vomitus or secretions can easily drain out of the mouth, reducing the risk of aspiration pneumonia and other respiratory complications. Option B, placing the client in semi-Fowler's position to promote oxygenation, is incorrect in this scenario because the priority post-ECT is to prevent aspiration rather than focusing solely on oxygenation. Placing the client in Trendelenburg's position (Option C) could actually be harmful as it may increase intracranial pressure and is not indicated for this situation. Option D, placing the client in a prone position to prevent airway blockage, is also incorrect as lying prone could further increase the risk of aspiration. In an educational context, understanding the rationale behind positioning post-ECT is essential for nurses working in psychiatric settings. It not only ensures the safety and well-being of the client but also demonstrates the nurse's knowledge of proper post-procedural care. By prioritizing the prevention of aspiration in this scenario, nurses can provide effective and evidence-based care to clients undergoing ECT.

Correct Answer: D

Rationale: In this scenario, option D, "The gun I got for my birthday is my most prized possession," is the most concerning statement made by the teenage male hospitalized after a failed suicide attempt. This statement raises red flags because it indicates that the individual may still have access to a potentially lethal means of self-harm, which increases the risk of a repeated suicide attempt. Option A is incorrect because it repeats the same statement as option D. Option B, "I don’t know why I get so depressed and want to die," while concerning, reflects a sense of confusion rather than immediate danger. Option C, "I don’t feel like I can talk to anyone about my feelings," is also worrying but does not pose an immediate threat to the individual's safety. Educationally, this question highlights the importance of assessing suicide risk factors, such as access to lethal means, in individuals who have attempted suicide. It emphasizes the critical role nurses play in identifying and addressing potential risks to ensure the safety and well-being of patients experiencing psychiatric crises. By understanding the significance of statements like the one in option D, healthcare providers can intervene effectively to prevent further harm and provide appropriate support and interventions.

Correct Answer: A

Rationale: In this scenario, the correct nursing diagnosis is A) Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at an increased risk for suicidal ideation or behavior. The nurse must assess this risk to ensure the patient's safety. Option B) Anxiety related to sudden and abrupt lifestyle changes may be present, but it is not the priority in this case as the patient's risk for suicide takes precedence. Option C) Social isolation related to loss of existing family is a valid concern, but it is not as urgent as the risk for suicide, which requires immediate attention. Option D) Spiritual distress related to anger with God is important to address but is not the priority when the patient's life is at risk. In an educational context, this question highlights the importance of prioritizing nursing interventions based on the level of risk to the patient. Understanding how to identify and address immediate life-threatening concerns is crucial in psychiatric nursing practice. It emphasizes the need for thorough assessment and critical thinking to provide safe and effective care to patients in vulnerable situations.

Correct Answer: C

Rationale: The nurse is responsible for the patient’s safety, including the appropriate use of restraints and ensuring the patient is monitored appropriately. The nurse is accountable for assessing the need for restraints, their proper application, and ongoing evaluation of the patient’s condition while restrained

Correct Answer: B

Rationale: The best question to begin assessing for suicidal ideation in an elderly patient is option B: "Are there any things going on in your life that would cause you to consider suicide?" This question is open-ended, non-judgmental, and directly addresses the patient's current life stressors or challenges that may be contributing to suicidal thoughts. Option A is not the best choice because it focuses on the patient's beliefs about the right to die, which may not directly reveal their current suicidal ideation. Option C is not ideal as it asks about vulnerability to depression rather than directly addressing suicidal thoughts. Option D is less effective as it assumes the patient would disclose their feelings of suicidality, which they may not feel comfortable doing initially. In an educational context, it is vital to teach healthcare providers to use open-ended questions to assess suicidal ideation effectively. By starting with a question that explores the patient's current stressors or triggers, nurses can gather valuable information to assess the patient's suicide risk accurately and provide appropriate interventions. This approach also helps build rapport and trust with the patient, fostering a therapeutic relationship conducive to honest communication about sensitive topics like suicidal thoughts.