Which intervention will the nurse implement in the first half hour after the patient has received ECT?

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: 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.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues. Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.

Correct Answer: A

Rationale: The correct answer is A because the patient whose 16-year-old daughter was raped and killed while going on an errand for the patient is at highest risk for dysfunctional grief. This traumatic and unexpected loss of a child to a violent act can lead to complicated or prolonged grief reactions. The sudden and violent nature of the death, along with the added trauma of rape, can significantly impact the grieving process. The intense emotions and feelings of guilt, anger, and helplessness may complicate the bereavement process and lead to dysfunctional grief reactions. Summary: Choice B is incorrect because the death of an 86-year-old mother after a long illness, although sad, does not necessarily indicate a higher risk of dysfunctional grief. Choice C is incorrect as attending a support group and receiving assistance from hospice are positive factors that can support healthy grieving. Choice D is incorrect as attending a bereavement group and learning to express feelings after the deaths of twin daughters indicate active engagement in the grieving process, which is

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: D

Rationale: The correct answer is D: Ask clear, simple questions using concrete language. This strategy is most helpful because older adults with schizophrenia may have cognitive impairments that affect their ability to process complex information. Clear and simple questions using concrete language can help the patient understand and respond effectively. Choice A (Ask questions that can be answered with yes or no) limits communication and may not provide enough information for the nurse to assess the patient's condition comprehensively. Choice B (Use silence often and let the patient take the lead) may not be effective as the patient may struggle to communicate effectively due to cognitive impairments. Choice C (Use open-ended, indirect questions) may lead to confusion or misinterpretation for a patient with cognitive challenges.

Correct Answer: C

Rationale: The correct answer is C because it accurately reflects the known side effect of ECT, which is temporary short-term memory loss. This statement indicates the patient comprehends the potential cognitive impact of the treatment. A is incorrect because it does not address specific side effects of ECT. B is incorrect as it implies a misconception that only one session is needed. D is incorrect as ECT does not guarantee that depression will never return.

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: 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.