VATI PN Mental Health Assessment With Best Solutions

VATI PN Mental Health Assessment With Best Solutions A nurse is assisting with the care of a client immediately following electroconvulsive therapy (ECT). Which of the following findings should the nurse document as an unexpected response to the procedure? -Correct Answer-Irregular heart rhythm An irregular heart rhythm is an unexpected response to ECT. During the procedure, the client's heart can be stressed, which can cause cardiac abnormalities. especially if the client already has impaired cardiac function. The nurse should document this finding and notify the charge nurse or the client's provider. A nurse is caring for a client who is admitted for alcohol use disorder. The client states, "I have not had anything to drink for 24 hours." Which the following is the priority nursing intervention? -Correct Answer-Check the client's vital signs. Clients who have alcohol use disorder are at risk for the development of abstinence syndrome. Manifestations of abstinence syndrome occur 12 to 72 hr after the client has last consumed alcohol and can include tachycardia, hypertension, and an elevated temperature. Therefore, the first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to check the client's vital signs to monitor for signs of abstinence syndrome. A nurse is reinforcing teaching with the adult child of a client who is scheduled to have electroconvulsive therapy (ECT). Which of the following statements should the nurse make? -Correct Answer-"Your father might experience short-term memory loss after the procedure." The nurse should reinforce to the client's child that short-term memory loss is a common adverse effect of ECT. A nurse is assisting with planning care for a client who is in the manic phase of bipolar disorder. Which of the following actions is the priority for the nurse to include in the plan? -Correct Answer-Offer frequent high-calorie fluids throughout the day. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for food and fluids. The priority nursing action is to the client high-calorie fluids to prevent dehydration and ensure the client's caloric is adequate to meet intake physical needs.