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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While new management's expectations are important, they are not as immediate a concern as job security during restructuring.
Choice B reason: Changes in job descriptions can be a concern, but they are secondary to the more pressing issue of whether employees will retain their jobs.
Choice C reason: Job security is typically the most pressing concern for employees during restructuring, as it directly impacts their livelihood and future with the company.
Choice D reason: Potential changes in employee benefits are important but are generally less immediate than concerns about job security.
Correct Answer is A
Explanation
Choice A reason: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.
Choice B reason: While immediate medical evaluation is important, it is not specified that the symptoms are severe or life-threatening, so it may not be the best initial advice.
Choice C reason: Diet changes can help manage symptoms of heartburn and indigestion, but they may not be sufficient if an ulcer is present.
Choice D reason: It is incorrect to assure the client that the symptoms are only reflux, as ulcer pain can indeed be relieved by food, contrary to the statement.
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