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 C
Explanation
Choice A reason: Mild sedation is a common and expected side effect of ramelteon, which is a sedative used to treat insomnia. It is generally not a cause for concern unless it persists or worsens.
Choice B reason: Dizziness reported after the initial dose is also a common side effect of ramelteon. It usually diminishes as the body adjusts to the medication. However, if dizziness persists or is severe, it should be reported to the healthcare provider.
Choice C reason: Somnambulism, or sleepwalking, is a serious side effect that should be reported to the healthcare provider immediately. Ramelteon can cause people to engage in activities while not fully awake and have no memory of the activity afterward. This could include walking, driving, eating, or making phone calls, and poses a significant safety risk.
Choice D reason: A change in the sleep-wake cycle is an expected effect of ramelteon, as it is used to manage the sleep-wake cycle in people with insomnia. It is not typically a side effect that needs to be reported unless the changes are extreme or cause significant distress.
Correct Answer is ["B","C","D","F"]
Explanation
Choice A Reason: Selecting only food items with no fat is not recommended because some fats, particularly unsaturated fats, are beneficial for health and should be included in a balanced diet.
Choice B Reason: Taking a cinnamon supplement may be beneficial as some studies suggest that cinnamon can help lower blood sugar levels and improve insulin sensitivity.
Choice C Reason: Minimizing the number of refined grains in the diet is advised because refined grains can have a negative impact on blood sugar control and may increase the risk of type 2 diabetes.
Choice D Reason: Eliminating sugary beverages and juices from the diet is beneficial as these can lead to spikes in blood sugar levels and contribute to weight gain, which is a risk factor for type 2 diabetes.
Choice E Reason: Doubling the usual amount of protein in the diet is not necessary and could lead to an excessive intake of calories. Protein should be consumed in moderation and as part of a balanced diet.
Choice F Reason: Increasing the amount of dietary fiber is recommended because fiber can help manage blood sugar levels and reduce the risk of developing type 2 diabetes.
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