Nursing Elites

1. What is the highest priority for post ECT care?

• A. Observe for confusion
• B. Monitor respiratory status
• C. Reorient to time, place, and person
• D. Document the client's response to the treatment

Correct answer: B

Rationale: The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.

2. Which of the following is an example of a breach of a client's right to privacy?

• A. A nurse who is not caring for the client reads the client's personal information in the chart
• B. A client is not allowed to keep a copy of their original medical record
• C. A nurse files an incident report about a client that is reviewed with all staff at a meeting
• D. A client's photograph is used without permission for the hospital newsletter

Correct answer: D

Rationale: A breach of a client's right to privacy can occur when their personal information is used or disclosed without their consent. In this scenario, using a client's photograph without permission for the hospital newsletter violates their privacy rights. It is important to respect a client's confidentiality and seek their consent before using their personal information. Choices A, B, and C do not directly relate to breaching a client's right to privacy. Reading a client's personal information in their chart, not allowing a client to keep a copy of their medical record, and filing an incident report about a client do not necessarily violate their privacy rights as long as the information is handled appropriately and within legal and ethical boundaries.

3. A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?

• A. Delirium
• B. Muscle rigidity
• C. Hypotension
• D. Pinpoint rash

Correct answer: A

Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.

4. The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?

• A. ''All elderly individuals experience depression occasionally.''
• B. ''I'm relieved that I will improve within 2 or 3 days.''
• C. ''I never realized depression could occur without a specific cause.''
• D. ''Reducing stress in my life will alleviate the depression.''

Correct answer: C

Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.

5. Examples of preservation of self-integrity include all of the following except:

• A. Using assistive equipment to move bariatric clients
• B. Participating in wellness programs
• C. Accepting the challenge of caring for clients with oppositional beliefs or practices
• D. Using hand hygiene and personal protective equipment

Correct answer: C

Rationale: Preservation of self-integrity involves actions that support the nurse's well-being and ethical standards. Using assistive equipment to move bariatric clients and practicing hand hygiene and personal protective equipment are essential aspects of maintaining physical health and safety, contributing to self-care. Participating in wellness programs further enhances self-care by promoting overall well-being. However, accepting the challenge of caring for clients with oppositional beliefs or practices can be emotionally taxing and may compromise a nurse's self-integrity if it leads to significant moral distress or ethical conflicts. In such situations, it is important for nurses to prioritize their well-being and ethical values by seeking alternative solutions or support.

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