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 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.

A. Assess for discomfort when the procedure is completed. B. Instruct the client to keep hands under the sterile field. C. Pour cleansing solution onto the sterile cloth field. D. Verify that the client has given informed consent. E. None F. None

Correct Answer is D

Explanation

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

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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

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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