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: 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: 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: B

Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves carrying out the plan of care. Encouraging the patient to attend a psychoeducational group daily is an action that is part of implementing the care plan to improve social skills. This step focuses on putting the plan into action and actively supporting the patient in achieving the desired outcomes. A: Assessment is incorrect because assessment involves collecting data and information about the patient's condition, not actively implementing interventions. C: Analysis is incorrect as it involves interpreting and making sense of the assessment data to identify problems and strengths, not implementing interventions. D: Evaluation is incorrect because it involves assessing the effectiveness of the interventions implemented, not actively carrying out the interventions themselves.

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.

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: B

Rationale: The correct answer is B because it captures the essence of bereavement - the experience of loss. This choice acknowledges that bereavement involves losing something significant, which is a universal aspect of grieving. Other choices are incorrect - A is not always predictable, C is not always acute depression, and D focuses on a specific aspect of grief rather than the core element of loss. Therefore, B is the most comprehensive and inclusive choice.

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: 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.