NCLEX Alternate Item Qs

The nurse is preparing a client for electroconvulsive therapy (ECT). The family of the client asks the nurse about this treatment. The nurse responds, knowing that which statements are accurate regarding this treatment? Select all that apply. 1. The average series involves 6 to 12 treatments. 2. Some confusion may be noted after the procedure. 3. Memory loss will occur but will resolve with time. 4. This treatment is a permanent cure to the condition. 5. This treatment is tried before the use of medications.

Correct: 1, 2, 3 (got right!) 1. The average series involves 6 to 12 treatments. 2. Some confusion may be noted after the procedure. 3. Memory loss will occur but will resolve with time. ECT as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition.

The nurse is preparing a client for electroconvulsive therapy (ECT), which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1. Obtain an informed consent. 2. Have the client void before the procedure. 3. Remove dentures and contact lenses before the procedure. 4. Withhold food and fluids for 6 hours before the treatment. 5. Administer tap water enemas on the evening before the procedure.

Correct: 1, 2, 3, 4 1. Obtain an informed consent. 2. Have the client void before the procedure. 3. Remove dentures and contact lenses before the procedure. 4. Withhold food and fluids for 6 hours before the treatment. Enemas are not a component of the pretreatment care for a client scheduled for ECT. Options 1, 2, 3, and 4 are a part of the pretreatment plan. Additionally, the nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure.

The nurse is developing a plan of care for a client with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. 1. Assist the client in selecting foods from the food menu. 2. Offer high-calorie fluids throughout the day and evening. 3. Allow the client to eat alone in the room if the client requests to do so. 4. Offer small high-calorie, high-protein snacks during the day and evening. 5. Select the foods for the client to be sure that the client eats a balanced diet.

Correct: 1, 2, 4 1. Assist the client in selecting foods from the food menu. 2. Offer high-calorie fluids throughout the day and evening. 4. Offer small high-calorie, high-protein snacks during the day and evening. In caring for a client with depression whose nutritional intake is poor, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.

The nurse is developing a plan of care for the client with a diagnosis of paranoia and should include which interventions in the plan of care? Select all that apply. 1. Provide a warm approach to the client. 2. Ask permission before touching the client. 3. Eliminate physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client.

Correct: 2, 3, 4, 5 2. Ask permission before touching the client. 3. Eliminate physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client. When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.