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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk.
Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments.
Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition.
Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus.
Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.
Normal Ranges:
- BMI: 18.5 to 24.9 kg/m² (normal)
- HDL (High-Density Lipoprotein): Greater than 45 mg/dL (Greater than 1.15 mmol/L)
- LDL (Low-Density Lipoprotein): Less than 130 mg/dL (Less than 3.4 mmol/L)
- Fasting Blood Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)
Correct Answer is ["A","B","D","F"]
Explanation
Choice A reason: Walking frequently during recovery is essential for preventing blood clots, improving circulation, and aiding in the healing process. It is recommended for patients to start with short, frequent walks and gradually increase the distance as tolerated. This helps to enhance physical activity and supports weight loss maintenance post-surgery.
Choice B reason: After bariatric surgery, patients are typically started on a clear liquid diet and then advanced to full liquids before progressing to pureed foods and eventually solid foods. This gradual progression is necessary to allow the stomach to heal and to avoid complications such as leaks or obstructions at the surgical site.
Choice D reason: Patients who have undergone bariatric surgery are at risk for nutritional deficiencies due to the reduced intake and absorption of nutrients. Therefore, taking prescribed vitamin and mineral supplements is crucial to prevent deficiencies and ensure adequate nutrition.
Choice F reason: Starting with room temperature water can help prevent discomfort and gastrointestinal symptoms that may occur when drinking cold fluids after surgery. Room temperature fluids are generally better tolerated in the immediate postoperative period.
Choice C reason: While weight loss is expected after bariatric surgery, it is not accurate to anticipate that weight loss will continue with a normal diet. Patients must adhere to a specific postoperative diet and lifestyle changes to ensure continued weight loss and avoid weight regain.
Choice E reason: Ovulation and fertility can be affected by significant weight loss; however, it is not appropriate to expect an immediate return of ovulation post-surgery. Fertility changes can vary from person to person and may take time.
Choice G reason: Encouraging three large meals a day is contrary to the recommended dietary guidelines post-bariatric surgery. Patients are advised to eat small, frequent meals to accommodate the reduced stomach capacity and to prevent symptoms of dumping syndrome.
Choice H reason: Dietician appointments are not optional but are a critical component of postoperative care. Regular follow-up with a dietician ensures that patients receive personalized nutritional guidance and support as they adjust to their new dietary habits.
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