Chapter 20. Electroconvulsive Therapy (Practice)

6. Sam has a diagnosis of major depression. After an unsuccessful trial of antidepressant medication, Sam's physician has hospitalized him for a course of ECT treatments. Sam says to the nurse on admission, "I don't want to end up like McMurphy in One Flew Over the Cuckoo's Nest! I'm scared!" What is Sam's priority nursing diagnosis at this time? a. Anxiety related to deficient knowledge about ECT b. Risk for injury related to risks associated with ECT c. Deficient knowledge related to negative media presentation of ECT d. Acute confusion related to side effects of ECT

ANS: A

3. Which of the following conditions increases the risk of adverse events associated with ECT? (Select all that apply.) a. Increased intracranial pressure b. Recent myocardial infarction c. Severe underlying hypertension d. Congestive heart failure e. Breast cancer

ANS: A, B, C, D

20. Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply. A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy

ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential

1. Electroconvulsive therapy is most commonly prescribed for which of the following? a. Bipolar disorder, manic b. Paranoid schizophrenia c. Major depression d. Obsessive-compulsive disorder

ANS: C

10. Succinylcholine is administered to a client receiving ECT for what purpose? a. To alleviate anxiety b. To decrease secretions c. To relax muscles d. As a short-acting anesthetic

ANS: C

5. After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, I cant even remember eating breakfast, so I want to stop the ECT. Which is the most appropriate nursing reply? A. After you begin the course of treatments, you must complete all of them. B. Youll need to talk with your doctor about what youre thinking. C. It is within your right to discontinue the treatments, but lets talk about your concerns. D. Memory loss is a rare side effect of the treatment. I dont think it should be a concern.

ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the clients concerns so that the nurse can provide needed information. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

11. A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve? A. The client will verbalize an understanding of the need for moving slowly after treatment. B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment. C. The client will continue adequate tissue perfusion 1 hour after treatment. D. The client will verbalize an understanding of common side effects of ECT.

ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity

5. The most common side effects of ECT are: a. Permanent memory loss and brain damage. b. Fractured and dislocated bones. c. Myocardial infarction and cardiac arrest. d. Temporary memory loss and confusion.

ANS: D

8. What is the priority nursing intervention before starting ECT therapy? a. Take vital signs and record. b. Have the patient void. c. Administer succinylcholine. d. Ensure that the consent form has been signed.

ANS: D

15. When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize? A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder

ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

9. A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action? A. The nurse notifies the clients physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room. C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the clients fluid intake to facilitate the digestive process.

ANS: A A client who is scheduled for ECT procedures is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

4. A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention? A. Suicide assessment must continue throughout the ECT course. B. Antidepressant medications are contraindicated throughout the ECT course. C. Discourage expressions of hopelessness throughout the ECT course. D. Encourage a high-caloric diet throughout the ECT course.

ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom. Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

6. Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, Im not hungry and just want to stay in bed and sleep. On the basis of this information, which is the most appropriate nursing intervention? A. Allow the client to remain in bed. B. Encourage the client to join the milieu to promote socialization. C. Obtain a physicians order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation.

ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

2. Immediately after electroconvulsive therapy, in which position should a nurse place the client? A. On his or her side to prevent aspiration B. In semi-Fowlers position to promote oxygenation C. In Trendelenburgs position to promote blood flow to vital organs D. In prone position to prevent airway blockage

ANS: A The nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

17. A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply. A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder

ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression, acute mania, and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

19. During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply. A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss

ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated. KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity

18. Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply. A. Electrocardiographic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results

ANS: A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the clients physician. The client must be medically cleared prior to ECT. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

2. Which of the following best describes the average number of ECT treatments given and the timing of administration? a. One treatment per month for 6 to 12 months b. One treatment every other day, three times a week for a total of 6 to 12 treatments c. One treatment three times per week for 6 to 12 months d.One treatment every day for a total of 10 to 20 treatments

ANS: B

4. A patient has been ordered ECT and asks the nurse, "Exactly how does ECT work?" Which of the following is the most accurate response by the nurse? a. "I'm not allowed to tell you that because that would be informed consent." b. "The exact mechanism is unknown, but there are several ways that ECT may have antidepressant effects." c. "The administration of a shock to the brain induces memory loss, which will make you forget you are depressed." d. "The neuroplasticity affected by seizure activity prevents further brain damage."

ANS: B

9. Atropine sulfate is administered to a client receiving ECT for what purpose? a. To alleviate anxiety b. To decrease secretions c. To relax muscles d. As a short-acting anesthetic

ANS: B

12. A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the clients lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply? A. The cuff has to be placed on the leg because both arms are used for intravenous fluids. B. The cuff functions to prevent succinylcholine from reaching the foot. C. The cuff position gives a more accurate blood pressure reading during the treatment. D. The cuff is placed on the leg so that arms can easily be restrained during seizure.

ANS: B A blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

3. A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. During ECT a state of euphoria is induced. B. ECT induces a grand mal seizure. C. During ECT a state of catatonia is induced. D. ECT induces a petit mal seizure.

ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

13. A client states, My doctor has told me I am a candidate for electroconvulsive therapy (ECT). Where will the treatment take place, and how much time would this entail? Which is the most accurate nursing reply? A. Clients typically receive ECT in their hospital room, daily for 1 month. B. Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting. C. Clients typically receive an unlimited number of treatments, in the hospital procedure room. D. Clients typically receive two to three treatments, in either an outpatient or inpatient setting.

ANS: B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures. Treatments are usually administered every other day, three times per week. Treatments are performed on either an inpatient or outpatient basis, depending on the need for client monitoring. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

14. A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. Which information should a nurse include when teaching about the potential side effects of this procedure? A. You may experience transient tangential thinking. B. You may experience some memory deficit surrounding the ECT. C. You may experience avolution for the remainder of the day. D. You may experience a higher risk for subsequent seizures.

ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

7. Sam, who has been hospitalized for ECT treatments, says to the nurse on admission, "I don't want to end up like McMurphy in One Flew Over the Cuckoo's Nest! I'm scared!" Which of the following statements would be most appropriate by the nurse in response to Sam's expression of concern? a. "I guarantee you won't end up like McMurphy, Sam." b. "The doctor knows what he is doing. There's nothing to worry about." c. "I know you are scared, Sam, and we're going to talk about what you can expect from the therapy." d. "I'm going to stay with you as long as you are scared."

ANS: C

16. A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would impact the feasibility of this treatment option? A. Because the client is extremely suicidal, ECT is an appropriate option. B. Because antidepressant medications have been ineffective, ECT is a good alternative. C. Because informed consent is required for ECT, cognitive deficits could preclude this option. D. Because of the clients cognitive deficits, a signed consent is waived.

ANS: C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the clients level of competency and, if necessary, the judge would appoint a guardian. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment Multiple Response

10. A client who is learning about electroconvulsive therapy (ECT) asks a nurse, Isnt this treatment dangerous? Which is the most appropriate nursing reply? A. No, this treatment is side-effect free. B. There can be temporary paralysis, but full functioning returns within 3 hours of treatment. C. There are some risks, but a thorough examination will determine your candidacy for ECT. D. Transient ischemic attacks (TIAs) can occur but are rare.

ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Reduction of Risk Potential

8. A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT. B. Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration. C. Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious. D. Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure.

ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously a short-acting anesthetic such as thiopental sodium (Pentothal). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurses rationale for this procedure? A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity

ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medication-induced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

7. A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a clients electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication? A. Robinul decreases anxiety during the ECT procedure. B. Robinul induces an unconscious state to prevent pain during the ECT procedure. C. Robinul prevents severe muscle contractions during the ECT procedure. D. Robinul decreases secretions to prevent aspiration during the ECT procedure.

ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT procedures to decrease secretions and prevent aspiration. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies