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","C","D"]
Explanation
The correct answer is: a, c, d.
Choice A: Avoid prolonged standing or sitting
Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.
Choice B: Cross legs at the knee but not at the ankle
Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.
Choice C: Continue wearing compression stockings
Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.
Choice D: Use a recliner for long periods of sitting
Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.
Choice E: Maintain the bed flat while sleeping
Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.
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.
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