A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?
Right lower abdominal pain.
Peripheral neuropathy.
Confusion.
Depression.
The Correct Answer is C
Choice A reason: Right lower abdominal pain is not typically associated with Wernicke's syndrome and would likely indicate a different issue.
Choice B reason: Peripheral neuropathy can be a symptom of Wernicke's syndrome, but it is not as central to the condition as confusion, which is a hallmark sign.
Choice C reason: Confusion is a primary symptom of Wernicke's syndrome and should be used in planning the client's care, as it indicates acute encephalopathy and the need for immediate treatment with thiamine.
Choice D reason: Depression may be present in clients with Wernicke's syndrome, but it is not a primary assessment finding used to plan care for the acute stage of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Asking the client to describe the pain is essential as it provides subjective information about the pain's quality, intensity, and impact on daily activities, which is crucial for assessing osteoarthritis pain.
Choice B reason: Observing body language and movement can offer insights into the pain's impact on function, but it does not replace the client's verbal description of the pain experience.
Choice C reason: Identifying effective pain relief measures is part of managing osteoarthritis but does not directly assess the quality of the client's knee pain.
Choice D reason: Providing a numeric pain scale is a method to quantify pain intensity but may not fully capture the quality or characteristics of the pain.

Correct Answer is ["A","B","D","E","F","G"]
Explanation
Choice A Reason: Allowing for menu deviations can help accommodate the patient’s preferences and encourage eating, which is crucial for recovery from emaciation.
Choice B Reason: Setting precise mealtimes can provide structure and consistency, which may help the patient establish regular eating habits.
Choice C Reason: Encouraging exercise is not appropriate at this stage due to the patient’s bradycardia and low BMI, which indicate a high risk for physical complications.
Choice D Reason: Monitoring trips to the restroom is important to prevent purging behaviors, which can be a concern in patients with eating disorders.
Choice E Reason: Providing family education on the condition is essential to ensure that the family understands the patient’s needs and how to support her recovery.
Choice F Reason: Weighing the patient twice weekly can help monitor her progress and adjust the treatment plan as needed.
Choice G Reason: Acknowledging feelings of anxiety is important for addressing the psychological aspects of the patient’s condition and promoting a supportive environment.
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