Question

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

Answer 1

Correct Answers:

Check the client's condition after the procedure.

Rationale :

🟢 The assistive personnel (AP) can appropriately be delegated post-procedure observations, such as checking vital signs and level of consciousness once the nurse has assessed initial stability.

🟢 This task does not require clinical decision-making, making it suitable for delegation under the five rights of delegation.

🟢 The AP can report findings back to the nurse, who will evaluate whether further intervention is necessary.

🟢 More complex actions like medication administration, informed consent witnessing, or first ambulation require a licensed nurse.

🟢 Delegation helps improve efficiency while ensuring the nurse retains accountability for the overall care plan.

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Answer 2

Correct Answers:

Failure to recognize familiar objects.

Rationale :

🔵 In Alzheimer’s disease, one of the hallmark symptoms is agnosia, the inability to recognize objects, people, sounds, or smells that were previously familiar.

🔵 This impairment reflects progressive neurodegeneration affecting the temporal and parietal lobes.

🔵 Other cognitive deficits include memory loss, disorientation, and impaired executive functioning.

🔵 Clients may struggle with ADLs and safety, requiring increasing support as the disease progresses.

🔵 Recognition failure is a key indicator used during assessment and staging of Alzheimer’s.

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Answer 3

Correct Answers:

The client has several siblings.

Rationale :

🟣 Having multiple siblings, especially in an environment lacking consistent structure or supervision, may contribute to the development of conduct disorder.

🟣 Larger family systems sometimes experience divided attention or ineffective discipline, increasing the risk of behavioral problems.

🟣 Conduct disorder is linked to disrupted attachment, exposure to chaotic households, and poor role modeling.

🟣 This risk factor is not causal on its own but contributes when combined with other biological or psychosocial influences.

🟣 Family-related contributors are emphasized in behavioral and developmental psychology models.

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Answer 4

Correct Answers:

Hyperthermia .

Rationale :

🟠 Alcohol withdrawal syndrome can cause hyperthermia, which is a result of autonomic hyperactivity and increased metabolic demands.

🟠 It often accompanies symptoms like tachycardia, hypertension, tremors, agitation, and in severe cases, seizures or delirium tremens.

🟠 Hyperthermia signals potential neurologic instability and must be addressed to prevent complications.

🟠 Monitoring vital signs and mental status is critical to assess progression and guide benzodiazepine administration.

🟠 Recognizing autonomic instability early is key in withdrawal management protocols.

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Answer 5

Correct Answers:

"I don't feel anything but numbness anymore."

Rationale :

🔴 Numbness or emotional detachment may indicate clinical depression, particularly if it persists and affects functioning.

🔴 While grief can involve sadness or anger, prolonged lack of affect or apathy suggests a pathological reaction.

🔴 Depression often presents with anhedonia, hopelessness, and difficulty connecting emotionally.

🔴 This differs from normal grief, which usually retains emotional fluctuation and meaningful support responses.

🔴 The provider must evaluate for major depressive disorder or complicated grief requiring treatment.

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Answer 6

Correct Answers:

Document the client’s refusal of the treatment in the medical record.

Rationale :

🟤 Even when a client is involuntarily committed, they retain the right to informed consent and refusal for most treatments, including ECT.

🟤 The nurse must respect autonomy and document the refusal while notifying the care team.

🟤 Exceptions occur only under emergency psychiatric holds with court orders.

🟤 Forced treatment without consent may constitute a legal and ethical violation.

🟤 This situation requires clear documentation, provider involvement, and possibly ethics consultation.

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Answer 7

Correct Answers:

Document the clients behavior every 15min.

Rationale :

🟢 While in seclusion, the nurse must frequently observe and document the client's status to ensure safety and legal compliance.

🟢 Guidelines typically require behavioral checks and documentation every 15 minutes, sometimes more often depending on policy.

🟢 This includes mental status, behavior, needs, and physical condition.

🟢 Failure to document can result in legal repercussions and compromise patient rights.

🟢 Seclusion is considered a restrictive intervention, and close monitoring is mandatory.

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Answer 8

Correct Answers:

"Let's discuss what you feel embarrassed about."

Rationale :

🔵 This therapeutic response promotes exploration of feelings without judgment, encouraging openness and trust.

🔵 It uses reflective communication to focus on the client’s emotions, not just the behavior.

🔵 Avoiding assumptions or pressure allows the client to safely disclose sensitive information.

🔵 The nurse remains supportive without minimizing or pushing the client too quickly.

🔵 This approach is consistent with principles of client-centered therapy and trauma-informed care.

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Answer 9

Correct Answers:

A client who states she did not get a promotion because her boss dislikes her.

Rationale :

🟣 Rationalization is a defense mechanism where individuals offer a logical but untrue explanation to justify behavior or outcomes.

🟣 In this case, the client avoids confronting potential personal shortcomings by blaming the boss.

🟣 This helps preserve self-esteem but interferes with realistic self-assessment.

🟣 Rationalization is a common mechanism seen in interpersonal conflict, failure, and rejection.

🟣 It may delay personal growth if not addressed therapeutically.

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Answer 10

Correct Answers:

Seizure disorder.

Rationale :

🔴 Aripiprazole is an atypical antipsychotic that can lower seizure threshold, increasing the risk of seizure activity.

🔴 Clients with a known seizure disorder require caution or alternative medications.

🔴 The prescriber must weigh the risks and consider using agents with lower neurologic adverse profiles.

🔴 Preexisting seizures are a relative contraindication to antipsychotics like aripiprazole, particularly at higher doses.

🔴 Thorough history-taking is necessary before initiating neuroactive medications.

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QLexNursing

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

2 :
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

3 :
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

4 :
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

5 :
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

6 :
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

7 :
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

9 :
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

10 :
A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

QLexNursing

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

2 : A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

3 : A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

4 : A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

5 : A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

6 : A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

7 : A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

8 : A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

9 : A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

10 : A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

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

2 :
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

3 :
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

4 :
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

5 :
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

6 :
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

7 :
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

9 :
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

10 :
A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?