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.

Answer and Explanation

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.

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Correct Answer is ["B","C"]

Explanation

Choice A reason: Telling the parents that the procedure is 100% effective and safe is misleading and unethical. No medical procedure can be guaranteed to be completely effective and without risk.
Choice B reason: Providing the parents with ideas about how to make their child feel better after the procedure can be comforting and can help them feel more involved and prepared for post-procedure care.
Choice C reason: Finding a comfortable area for the parents to wait that is close to the procedure area can help reduce their anxiety by keeping them informed and involved in the process.
Choice D reason: Limiting visitation can increase anxiety as it separates the parents from their child, which can be distressing for both the child and the parents.
Choice E reason: Not providing any specifics on the amount of time the procedure will take can increase anxiety due to uncertainty. It is better to give a realistic time frame when possible.

A. Sloughing tissue around wound edges. B. Loss of sensation to the left lower extremity. C. Weeping serosanguineous fluid from wounds. D. Reporting increased pain and pressure. E. Change in the quality of the peripheral pulses.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.

Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.

Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.

Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.

Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

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A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

Correct Answer is ["B","C"]

Explanation

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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