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 C

Explanation

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

A. "If I make the changes we talked about, 1 will not get type 2 diabetes." B. "I can never eat sugar again." C. "If my fasting blood sugar is less than 100 mg/dL (5.6 mmol/L) next time, 1 can go back to my usual eating habits." D. "Making these changes will also help me avoid other chronic health conditions." E. "If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Choice A reason: No understanding.

While lifestyle changes can significantly reduce the risk of developing type 2 diabetes, they do not guarantee prevention. The client’s family history and current prediabetic fasting blood glucose level (122 mg/dL) indicate an increased risk. It’s important to understand that while risk can be minimized, it cannot be completely eliminated12.

Choice B reason:
People with diabetes or prediabetes can still consume sugar, but it should be in moderation and as part of a balanced diet. The DASH diet discussed with the client emphasizes portion control and a reduction in sugar intake, not complete elimination.

Choice C reason: No understanding

A single fasting blood glucose measurement below 100 mg/dL does not mean the client can revert to previous eating habits. Ongoing maintenance of a healthy diet and lifestyle is necessary to manage blood glucose levels and reduce the risk of diabetes.

Choice D reason: Understanding.

Lifestyle changes such as adopting the DASH diet and increasing physical activity can help manage weight, improve cholesterol levels, and lower the risk of chronic conditions like hypertension, cardiovascular disease, and type 2 diabetes.

Choice E reason: Understanding.

Increased thirst and urination are symptoms of high blood sugar levels. If the client experiences these symptoms, it would be prudent to check blood glucose levels to manage and monitor for diabetes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Correct Answer is C

Explanation

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding no understanding of the education given.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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