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 A
Explanation
Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.
Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.
Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.
Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.
Correct Answer is A
Explanation
Choice A reason: The immediate activation of the lockdown procedure is critical in the event of a suspected infant abduction, as it helps to secure the facility and prevent the unauthorized removal of the infant.
Choice B reason: Matching ID bands is a standard procedure but not the first action to take in a potential abduction scenario.
Choice C reason: Asking the mother about expected visitors is part of the investigation but does not take precedence over securing the facility.
Choice D reason: Determining if the newborn is in the nursery is important but should follow the immediate security measures.
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