Which is the highest priority in the post-ECT care?
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Solution
Monitor respiratory status
A side effect of ECT which is life threatening is a respiratory arrest.
Options A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.
The following medications will likely be prescribed for the client EXCEPT:
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Solution
Zyprexa
This is an antipsychotic.
Option A: Prozac is a SSRI antidepressant.
Option B: Tofranil antidepressant belongs to the Tricyclic group.
Option C: Parnate is a MAOI antidepressant.
The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the appropriate nursing diagnosis?
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Solution
Low esteem related to failure to role performance
This indicates the client’s negative self-evaluation. A sense of worthlessness may accompany depression.
Options A, B, and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange
Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident. The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is:
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Solution
“I haven’t been able to open the door and go into my baby’s room.”
This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional.
Option A: This indicates acknowledgment of the loss. Expressing feelings openly is acceptable.
Option C: This indicates the stage of depression in the grieving process.
Option D: Remembering both positive and negative aspects of the deceased love one signals successful mourning.
Which is the best indicator of success in the long term management of the client?
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Solution
He learns to verbalize his feelings and concerns
The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors.
Option A: The client is encouraged to acknowledge feelings rather than being indifferent to her feelings.
Option B: Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success.
Option D: Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational.
When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.
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Solution
Answer: A, B, D.
A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life.
Option C: The degree of aggressiveness is typically out of proportion with the stressor. Option E: Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
Option E: Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
A nurse discusses job possibilities with a client with schizoid personality disorder. Which suggestion by the nurse would be helpful?
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Solution
“Your idea of applying for the position of filing and organizing records is worth pursuing.”
Clients with schizoid personality disorder prefer solitary activities, such as filing, to working with others. Working as a cashier or in customer service would involve interacting with many people.
A client with avoidant personality disorder says occupational therapy is boring and doesn’t want to go. Which action would be best?
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Solution
State firmly that you’ll escort him to OT.
If given the chance, a client with avoidant personality disorder typically elects to remain immobilized. The nurse should insist that the client participates in OT.
Options B and D: Arranging for the client to do a project on the unit validates and reinforces the client’s desire to avoid getting to OT.
Option C: Addressing an invalid issue such as the client’s perceived boredom avoids the real issue: the client’s need for therapy.
A client with schizotypal personality disorder is sitting in a puddle of urine. She’s playing in it, smiling, and softly singing a child’s song. Which action would be best?
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Solution
Help the client to the shower, and change the bedclothes.
A client with schizotypal personality disorder can experience high levels of anxiety and regress to childlike behaviors. This client may require help needing self-care needs. The client may not respond to the other options or those options may generate more anxiety.
Which of the following behaviors by a client with dependent personality disorder shows the client has made progress toward the goal of increasing problem solving skills?
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Solution
The client asks questions.
The client with a dependent personality disorder is passive and tries to please others. By asking questions, the client is beginning to gather information, the first step of decision making.