The standard procedure for modified electroconvulsive therapy (ECT) involves the administration of a specific sequence of medications to ensure patient safety and comfort. An anticholinergic agent, such as atropine, is given to decrease secretions and counteract vagal stimulation (bradycardia). A short-acting anesthetic, like methohexital (Sodium Brevital), is administered to induce unconsciousness. Finally, a neuromuscular blocking agent, such as succinylcholine chloride (Anectine), is used to produce muscle paralysis, preventing the motor component of the seizure and minimizing the risk of musculoskeletal injury. This combination is the established protocol for administering ECT.

A. Lithium is typically discontinued before ECT as it can increase the risk of neurotoxicity and prolong seizures. The other medications are not standard for the ECT procedure itself.

C. These are electrolytes. While their balance is important for general health, they are not the primary pharmacological agents administered to facilitate the ECT procedure.

D. Carbamazepine is an anticonvulsant, which would counteract the therapeutic goal of ECT by raising the seizure threshold, making it difficult to induce a seizure.

1. Halter, M. J. (2022). Varcarolis' Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach (9th ed.). Elsevier. In Chapter 15, "Brain Stimulation Therapies," the section on the ECT procedure details the use of a short-acting anesthetic (e.g., methohexital), a muscle relaxant (e.g., succinylcholine), and an anticholinergic agent (e.g., atropine or glycopyrrolate) (p. 277).

2. American Psychiatric Association. (2001). The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (A Task Force Report of the American Psychiatric Association) (2nd ed.). American Psychiatric Publishing. Chapter 8, "The Practice of ECT," outlines the standard anesthetic management, stating, "The anesthetic technique for ECT consists of the administration of an anticholinergic agent, an anesthetic agent, and a muscle relaxant" (p. 111). It lists atropine, methohexital, and succinylcholine as common examples.

3. Pagnin, D., de Queiroz, V., Pini, S., & Cassano, G. B. (2004). Efficacy of ECT in depression: a meta-analytic review. The Journal of ECT, 20(1), 13-20. https://doi.org/10.1097/00124509-200403000-00004. The "Methods" sections of studies included in this meta-analysis consistently describe the use of a short-acting anesthetic and a muscle relaxant as standard procedure for modified ECT.

The most appropriate statement is one that provides honest, age-appropriate, and sensory-based information without being overly frightening. For a 6-year-old (school-age) child, using familiar terms like "pinch" or "bug bite" helps them understand the sensation they might experience. This approach aligns with the principles of atraumatic care. Asking the child to describe the feeling afterward gives them a sense of control and involvement, which can reduce anxiety and promote coping. This method avoids false reassurance and negative language, fostering trust between the nurse and the child.

B. Stating the procedure will "hurt a lot" is overly negative and will significantly increase the child's fear and anxiety, making cooperation more difficult.

C. Labeling the procedure as "terrible" is unprofessional and introduces a high level of fear. Telling the child not to look can increase anxiety about the unknown.

D. This statement minimizes the child's potential pain, which can lead to a loss of trust. The phrase "be a big boy" is judgmental and discourages the child from expressing their feelings.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's nursing care of infants and children (11th ed.). Elsevier. In Chapter 36, "Pain Assessment and Management in Children," the text emphasizes preparing children for painful procedures by providing factual information in simple terms they can understand, such as describing the sensation as a "pinch" (p. 1045, Box 36.5).

2. Koller, D. (2008). Preparing children for medical procedures. Paediatrics & Child Health, 13(1), 33–36. https://doi.org/10.1093/pch/13.1.33. This article highlights the importance of providing sensory information (what the child will feel, see, hear) and avoiding false reassurance. It supports describing sensations in familiar terms to reduce distress (p. 34, "Provide sensory information").

3. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2014). Maternal child nursing care (5th ed.). Elsevier Mosby. Chapter 32, "Family-Centered Care of the Child During Illness and Hospitalization," advises nurses to "prepare the child for any unfamiliar procedure... by demonstrating on a doll... and describing the sensation—for example, 'a cool feeling when the skin is cleaned'" (p. 921). This supports the use of sensory-based, non-threatening descriptions.

An elective saline abortion involves the intra-amniotic infusion of a hypertonic saline solution. This concentrated salt solution is absorbed into the maternal circulation, leading to a rapid increase in serum sodium levels and plasma osmolality (hypernatremia). The body's primary compensatory mechanism for this hypertonic state is to stimulate the thirst center in the hypothalamus. This intense thirst is a direct and early physiological response aimed at increasing fluid intake to dilute the excess sodium and restore osmotic balance.

A. Water satiety: This is the opposite of the expected effect. The hypertonic state created by the saline infusion triggers a strong thirst mechanism, not a feeling of fullness from water.

C. Edema: While fluid shifts and potential fluid overload can occur, generalized edema is not an early or primary side effect. It would be a later sign of complications like heart failure or renal compromise.

D. Diabetes insipidus: This condition is characterized by excessive water loss due to an antidiuretic hormone (ADH) deficiency. The hypernatremia from saline infusion would stimulate ADH release to conserve water, not cause diabetes insipidus.

1. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Spong, C. Y. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education. In Chapter 18, "Abortion," the text discusses complications of various methods, noting that hypertonic saline instillation carries a significant risk of hypernatremia and subsequent central nervous system effects if absorbed systemically. The physiological response to hypernatremia is intense thirst.

2. Mezrow, G., Breen, J. L., & Vujic, I. (1990). Complications of second-trimester abortion by intraamniotic prostaglandin F2alpha and hypertonic saline. Journal of Reproductive Medicine, 35(8), 793-796. This article reviews complications, including the well-documented electrolyte disturbances such as hypernatremia resulting from systemic absorption of the saline, which clinically manifests as thirst.

3. Goodlin, R. C., McLennan, C. E., Choyce, J. M., Lee, R. S., & Stickler, J. E. (1972). The maternal-fetal-amniotic fluid-hypertonic-saline-abortion-syndrome. American Journal of Obstetrics and Gynecology, 114(7), 867-872. https://doi.org/10.1016/0002-9378(72)90169-8. This foundational paper describes the maternal physiologic responses, including a consistent rise in serum sodium and osmolality (p. 868), which is the direct trigger for the thirst mechanism.

Therapeutic play is a primary and highly effective method for helping school-aged children cope with significant emotional stress. Play-acting, or role-playing, allows siblings to express complex feelings such as fear, anger, or guilt in a safe and controlled manner. They can act out scenarios, explore different perspectives, and communicate anxieties they may be unable to verbalize. This active, expressive approach is developmentally appropriate and helps them process the difficult situation of a sibling's terminal illness, promoting understanding and coping.

A. Open discussion and understanding: While important, school-aged children may lack the vocabulary or emotional maturity to fully articulate their complex feelings through direct conversation alone.

C. Storytelling: Bibliotherapy can be a useful tool to normalize feelings, but it is a more passive approach and may not facilitate the direct expression of the child's unique, personal emotions.

D. Drawing pictures: Art therapy is also a valuable tool for non-verbal expression; however, role-playing is often more effective for exploring the specific interpersonal dynamics and communication challenges within the family.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's Nursing Care of Infants and Children (11th ed.). Elsevier. In the chapter on "The Child with a Life-Threatening Condition and End-of-Life Care," the text emphasizes therapeutic play as a key intervention for helping children express feelings and fears they cannot verbalize (See Chapter 17, section on "Interventions").

2. McCarthy, A. M., & Gallo, A. M. (2010). A model of family adaptation to childhood chronic illness. Journal of Pediatric Nursing, 25(5), 401-410. This article discusses the importance of interventions that support family communication. For school-aged siblings, play-based therapies are highlighted as essential for facilitating this communication and emotional expression. https://doi.org/10.1016/j.pedn.2010.04.006

3. Johns Hopkins School of Nursing. (n.d.). Care of the Child and Family Clinical Practicum Course Materials. Courseware often details age-appropriate psychosocial interventions, identifying therapeutic play (including role-playing) as a cornerstone of nursing care for school-aged children experiencing trauma or grief. It allows for mastery and control over overwhelming situations.

4. Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2017). Pediatric Primary Care (6th ed.). Elsevier. The text discusses developmental approaches to communication, noting that for school-aged children, play is a natural medium for expressing thoughts and feelings that are too difficult to state directly (See Chapter 5, "Communication and Interviewing").

An obstructing stone in the renal pelvis or upper ureter causes acute distention of the renal capsule and ureteral spasm, resulting in severe, colicky flank pain known as renal colic. The intensity of this pain often triggers a systemic sympathetic and vagal response via the celiac plexus. This stimulation leads to associated symptoms such as nausea, vomiting, diaphoresis, and pallor. This clinical presentation is the hallmark of an acute upper urinary tract obstruction.

A. Radiating pain to the groin, labia, or testicles is characteristic of a stone that has migrated to the lower third of the ureter.

B. Urinary frequency and dysuria are irritative voiding symptoms that typically occur when the stone is located at the ureterovesical junction, near the bladder.

D. Dull, aching back pain is more often associated with a non-obstructing stone within the renal calyces or a chronic, less severe obstruction.

1. Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier. Chapter 45, Urinary Tract Calculi, Clinical Manifestations section, p. 1031.

2. Johns Hopkins University School of Nursing. (n.d.). Nursing Care of the Patient with Renal Calculi. Courseware, Synthesis Practicum. The course materials describe the classic presentation of renal colic from upper ureteral obstruction as "acute, severe flank pain" accompanied by "nausea, vomiting, and diaphoresis."

3. Tefekli, A., & Cezayirli, F. (2013). The history of urinary stones. Urolithiasis, 41(6), 491–500. https://doi.org/10.1007/s00240-013-0613-8 (This article, in its review of clinical presentation, discusses the pathophysiology of renal colic, linking severe flank pain and associated systemic symptoms like nausea and vomiting to upper ureteral obstruction).

A rectal temperature of 102°F (38.9°C) is a significant finding that requires immediate reporting. A scalp laceration provides a direct portal of entry for microorganisms, placing the client at high risk for a central nervous system infection, such as meningitis or a brain abscess. Fever may be the first sign of such a life-threatening complication. Additionally, a high temperature can indicate hypothalamic dysregulation resulting from the head injury itself. Prompt physician notification is crucial for timely diagnosis and intervention, which may include blood cultures and initiation of antibiotic therapy.

A. This minor blood pressure fluctuation is within the normal range for an adolescent and can be caused by factors like pain or activity; it is not clinically significant.

B. While a headache unresponsive to analgesia is a concern for increasing intracranial pressure, a high fever suggests a new, acute infectious process, which is a more immediate life-threatening emergency.

C. A pulse rate between 68 and 76 bpm is a normal finding for a 14-year-old and does not indicate a complication such as the bradycardia seen with Cushing's triad.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's Nursing Care of Infants and Children (11th ed.). Elsevier. In Chapter 29, "The Child with a Neurologic Condition," the text emphasizes monitoring for signs of infection after head trauma, noting that fever can be an early indicator of meningitis or wound infection (pp. 878-880).

2. Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2021). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (10th ed.). Elsevier. Chapter 45, "Care of Patients with Problems of the Central Nervous System: The Brain," discusses that fever is a common complication after traumatic brain injury and must be reported, as it can indicate infection or hypothalamic damage and increases the metabolic demands of the brain (pp. 955-956).

3. University of Michigan, Department of Neurosurgery. (n.d.). Traumatic Brain Injury (TBI). Courseware materials for medical students and residents. The curriculum highlights that secondary insults after TBI, such as fever (hyperthermia) and infection, worsen patient outcomes and require aggressive management. Monitoring for and reporting fever is a critical nursing responsibility. (Section on Secondary Brain Injury).

Heparin is a potent anticoagulant used to treat thrombophlebitis. Its primary and most dangerous adverse effect is bleeding. An overdose exacerbates this risk, leading to signs of hemorrhage. The nurse must monitor for clinical indicators of excessive anticoagulation. Hematuria (blood in the urine), ecchymosis (unexplained bruising), and epistaxis (nosebleed) are all classic, direct signs of bleeding. Other signs include bleeding gums, tarry stools (melena), and petechiae. Prompt identification of these symptoms is critical for patient safety, especially in the postpartum period where the risk of hemorrhage is already elevated.

A. Dysuria (painful urination) is a classic symptom of a urinary tract infection, not a direct sign of heparin overdose.

B. This option incorrectly includes dysuria. While hematuria and epistaxis are correct, the presence of an incorrect sign makes the entire option less accurate.

C. This option incorrectly includes vertigo. Vertigo is not a primary sign of heparin overdose, though it could be a late symptom of hypovolemia from major blood loss.

1. Lilley, L. L., Rainforth, S. J., & Snyder, J. S. (2021). Pharmacology and the Nursing Process (10th ed.). Elsevier. In Chapter 26, "Anticoagulants," the text identifies bleeding as the main complication of heparin therapy, with signs including hematuria, melena, petechiae, ecchymoses, and gum or mucous membrane bleeding (p. 429).

2. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2018). Maternal Child Nursing Care (6th ed.). Elsevier. In Chapter 22, "Postpartum Complications," the nursing care plan for thromboembolic disease emphasizes assessing for evidence of bleeding, such as bleeding gums, nosebleeds, easy bruising, and hematuria, in clients receiving anticoagulant therapy (p. 549).

3. Hirsh, J., & Raschke, R. (2004). Heparin and Low-Molecular-Weight Heparin: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3suppl), 188S–203S. This guideline identifies bleeding as the major complication of heparin therapy and discusses the clinical spectrum of bleeding events, which includes hematuria and spontaneous ecchymoses. (Section: "Complications of Heparin Therapy," p. 196S). https://doi.org/10.1378/chest.126.3suppl.188s

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The client's elevated blood sugar levels during her current pregnancy, combined with the fact that she only exhibits these signs while pregnant, fits the precise definition of GDM. Her history of delivering a macrosomic infant (weighing 4536 g, which is >4000 g) is a significant risk factor for and a common clinical indicator associated with GDM in a previous pregnancy.

A. Insulin-dependent diabetes: This is an outdated term describing treatment (the need for insulin) rather than the underlying pathophysiology or type of diabetes.

B. Type II diabetes mellitus: This is a chronic metabolic disorder that persists outside of pregnancy. The scenario specifies the client only shows signs of diabetes when she is pregnant.

C. Type I diabetes mellitus: This is an autoimmune condition resulting in absolute insulin deficiency that would be present before, during, and after pregnancy, not just during gestation.

1. American Diabetes Association. (2022). 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2022. Diabetes Care, 45(Supplement1), S17–S38. https://doi.org/10.2337/dc22-S002

Page S27, Section "Gestational Diabetes Mellitus": Defines GDM as "diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation."

2. American College of Obstetricians and Gynecologists (ACOG). (2018). ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics & Gynecology, 131(2), e49-e64. https://doi.org/10.1097/AOG.0000000000002501

Page e50, "Background" section: Lists risk factors for GDM, including a "history of delivering an infant weighing 4,000 g or more."

3. Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and pediatric nursing (4th ed.). Wolters Kluwer.

Chapter 21, "Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations," Section "Diabetes Mellitus": Differentiates between pregestational diabetes (Type 1 or Type 2) and gestational diabetes, defining the latter as glucose intolerance that does not extend beyond the pregnancy.

The client's presentation is characteristic of conversion disorder, also known as Functional Neurological Symptom Disorder. This condition involves neurological symptoms, such as blindness, paralysis, or numbness, that cannot be explained by a medical evaluation or neurological condition. The onset of these symptoms is often associated with significant psychological stress or trauma, representing an unconscious "conversion" of emotional distress into a physical symptom. The diagnostic findings of no organic cause for the blindness, coupled with a history of recent trauma, strongly support this diagnosis.

A. Delusion: This is a fixed, false belief (a disturbance in thought content), not a physical sensory symptom like blindness.

B. Illusion: This is a misinterpretation of a real external sensory stimulus, such as seeing a shadow and thinking it is a person.

C. Hallucination: This is a false sensory perception without any real external stimulus, such as hearing voices when no one is present.

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). As cited in: Tollefson, J., & Bishop, L. (2021). Psychiatric-Mental Health Nursing: Foundational Concepts. University of West Florida Pressbooks. Chapter 10, "Somatic Symptom and Related Disorders," Section on Functional Neurological Symptom Disorder (Conversion Disorder). (This university courseware explains that the disorder involves one or more symptoms of altered voluntary motor or sensory function, with clinical findings showing incompatibility between the symptom and recognized neurological or medical conditions).

2. Aybek, S., & Perez, D. L. (2022). The clinical evaluation of functional neurological disorder. JAMA Neurology, 79(2), 203–212. https://doi.org/10.1001/jamaneurol.2021.4598 (This peer-reviewed article discusses the diagnostic criteria, emphasizing the essential rule-out of neurological disease and the frequent association with psychological stressors. See "Clinical Evaluation" section).

3. Reeves, R. R., & Ros-Rull, G. (2018). Differentiating Somatic Symptom Disorder, Functional Neurological Symptom Disorder, and Malingering. The Journal of the American Academy of Psychiatry and the Law, 46(3), 386–389. https://doi.org/10.29158/JAAPL.003781-18 (This publication clarifies the distinction between conversion disorder and other conditions, highlighting the lack of an organic basis for the neurological symptom).

The client is multiparous, fully dilated, and verbalizing the sensation of imminent birth ("the baby is coming"). This combination of factors strongly suggests the second stage of labor is progressing rapidly and birth is imminent. The nurse's immediate priority is to perform a rapid assessment to validate the client's statement. Inspecting the perineum for bulging or crowning of the fetal head is the most direct and definitive way to confirm this. This visual assessment will guide the nurse's next immediate actions, such as calling for assistance, providing perineal support, and preparing for an emergency delivery if the provider is not present.

B. Time the contractions.

Timing contractions is a key assessment during the first stage of labor but is a lower priority when birth is imminent in the second stage.

C. Prepare a sterile area for delivery.

This is an important intervention, but it must follow an assessment. The nurse must first confirm that birth is imminent before preparing the area.

D. Auscultate for fetal heart rate (FHR).

While monitoring FHR is crucial, visually confirming an impending birth takes precedence to prevent an uncontrolled delivery and ensure the safety of both mother and baby.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity & women's health care (12th ed.). Elsevier. In Chapter 17, "Nursing Care During Labor and Birth," the section on the Second Stage of Labor emphasizes that when a woman has a strong urge to push, the nurse should assess for perineal bulging and crowning as signs of imminent birth (pp. 408-409).

2. Durham, R. F., & Chapman, L. (2019). Maternal-newborn nursing: The critical components of nursing care (3rd ed.). F.A. Davis Company. Chapter 10, "Nursing Care During Labor and Birth," states that if a woman says, "The baby is coming," the nurse's first action should be to assess the perineum for crowning to prepare for imminent birth (p. 221, "Nursing Actions for Imminent Birth").

3. Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and pediatric nursing (4th ed.). Wolters Kluwer. Chapter 14, "Nursing Management During Labor and Birth," details the assessment during the second stage of labor, prioritizing the observation of perineal bulging and the visualization of the fetal head as indicators for immediate delivery preparations (p. 512).