Question

1. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to assistive personnel?

1. Assist the client to ambulate for the first time following the procedure
2. Check the client’s condition after the procedure
3. Witness the client’s signature on the consent for the procedure
4. Give the client atropine 30 mins before the procedure

2. A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?

1. “How have you deal with similar situations in the past?”
2. “Do you see your current situation affecting your future?”
3. “How does this situation affect your life?”
4. “Can you describe how you are currently feeling?”

3. A nurse conducting an admission interview with a new client who tells the nurse. “My life is so stressful. I can’t take it anymore.” Which of the following responses should the nurse take first?

1. “How have you dealt with stress in the past?”
2. “Let’s talk more about what you are experiencing.”
3. “Are you thinking of harming yourself?”
4. “Tell me what makes you feel stressed.”

4. A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate. Which of the following mediations should the nurse prepare to administer?

1. Naltrexone
2. Lorazepam
3. Methadone
4. Disulfiram

5. A nurse is caring for a school-age child who has a diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?

1. Valproate
2. Methylphenidate
3. Lithium
4. Risperidone

Answer 1

1. Answer Option A. Assist the client to ambulate for the first time following the procedure

Option A is correct as after the electroconvulsive therapy, the client usually feel disoriented after the procedure and requires assistance to ambulate as the disorientation can last from few minutes to few hours and assistance given by assistive personnel is important to prevent any risk of fall or injury with proper observation required.

Option B is incorrect as client's condition after the procedure is required to be checked by a qualified physician or a nurse so as to notice all the symptoms and determine the client's well being and safety from a medical stand point and not a job of assistive personnel

Option C is incorrect as it is the registered nurse's and responsibility of the physician to verify the consent forms

Option D is incorrect as assistive personnel cannot administer or prescribe any medication to the patient.

2. Answer Option A. “How have you deal with similar situations in the past?”

Option A is correct as the client's past experience with dealing with such situation will provide the nurse with the information if and whether the client has the coping skills and ability to deal with such situation and its effect with depression. Similar situation helps us to get access to the clients mindset and can help in correct diagnosis and assessment.

Option B is incorrect as asking about future is unpredictable and coping skills cannot be properly assessed by this question

Option C is incorrect as asking about the impact of job loss on life will only help in getting depression details and not the coping skills

Option D is incorrect as his current feelings are unstable and the answer given will only help with emotional assessment and not the coping skills

3. Answer Option B. “Let’s talk more about what you are experiencing.”

Option B is correct as the nurse has to obtain a clear picture before determining any harm or suicidal behavior and making a note in the interview. Most of the time the indications of stress do not lead to harm and even might have some other reasons. So asking about the current emotions and feelings the client is experiencing the nurse can further explore and get an idea of the root of the prole and its entire scope which can help in diagnosis and treatment

Option A is incorrect as past experiences cannot determine the current problem that the client is facing in terms of stress and experiences

Option C is incorrect as directly confronting the client with such question can lead to the client changing the topic or not revealing any further details and might not cooperate when asked on point directly

Option D is incorrect as asking about potential stressors can be helpful but also can be incorrect as the client might point to a problem which may not have the reason for his current feeling s and here the wider picture can help in the interview and assessments.

4, Answer Option A. Naltrexone

Option A is correct as Naltrexone is usually used for treatment in alcohol abuse and opioid dependence reduction. So a client when experiencing the symptoms of alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate can be given naltrexone. It can help with reducing the blood pressure to normal and also with tremor symptoms

Option B is incorrect as Lorazepam will not help in controlling the blood pressure and heart rate

Option C is incorrect as have adverse effects with reducing the blood pressure drastically further initiating the complications

Option D is incorrect as disupfram is used for sleep and acute alcohol sensitivity and cannot be used in this symptoms.