A client was admitted to the emergency department with slurred speech and impaired motor coordination. The blood alcohol level is over 300 mg/dL. The physician orders thiamine for the client. The nurse understands that the physician ordered thiamine to:

Prevent Wernicke's encephalopathy.

Prevent alcoholic hepatitis.

Rehydrate the client.

Prevent pancreatitis.

Answer and Explanation

The Correct Answer is A

Choice A Reason
Thiamine, or vitamin B1, is essential for brain function and the metabolism of carbohydrates. In the context of high blood alcohol levels, thiamine is administered to prevent Wernicke's encephalopathy, a serious neurological disorder. This condition is often precipitated by a thiamine deficiency, which can be exacerbated by alcohol abuse. Alcohol consumption can impair thiamine absorption and utilization, leading to depleted stores. Wernicke's encephalopathy is characterized by symptoms such as confusion, ataxia, and ophthalmoplegia, and if left untreated, it can progress to Korsakoff syndrome, a chronic and debilitating condition.

Choice B Reason
While alcoholic hepatitis is a concern in individuals with excessive alcohol intake, thiamine is not specifically used to prevent this condition. Alcoholic hepatitis is inflammation of the liver due to alcohol abuse, and its prevention primarily involves abstinence from alcohol, nutritional support, and medical management of liver inflammation. Thiamine does not play a direct role in preventing liver inflammation but is crucial for overall nutritional replenishment in individuals with alcohol use disorder.

Choice C Reason
Rehydration is indeed important for clients with high blood alcohol levels; however, thiamine does not serve this purpose. Rehydration typically involves the administration of intravenous fluids to restore fluid balance and electrolytes. Thiamine is not a rehydrating agent but is given to prevent neurological complications associated with thiamine deficiency, which can be seen in individuals with chronic alcoholism.

Choice D Reason
Preventing pancreatitis is not the primary reason for administering thiamine in this scenario. Pancreatitis, an inflammation of the pancreas, can be associated with chronic alcohol abuse, but thiamine is not used as a preventative treatment for this condition. The management of pancreatitis involves addressing the underlying causes, supportive care, and sometimes hospitalization for more severe cases.

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Correct Answer is A

Explanation

Choice A Reason:

Smoking, hypertension, obesity, diabetes, and hyperlipidemia are all well-established risk factors for heart disease. Smoking damages the lining of the arteries, leading to a buildup of fatty material which narrows the artery. Hypertension can cause hardening and thickening of the arteries, which can lead to a heart attack or stroke. Obesity increases the likelihood of high blood pressure, high cholesterol levels, and diabetes, all of which are risk factors for heart disease. Diabetes increases the risk of heart disease significantly, as high blood sugar levels can damage blood vessels and the nerves that control the heart. Hyperlipidemia, particularly high levels of LDL cholesterol, can lead to plaque buildup in the arteries, increasing the risk of heart attack or stroke.

Choice B Reason:

Family history is a non-modifiable risk factor for heart disease, as genetics can play a role in an individual's likelihood of developing heart conditions. Stress can contribute to heart disease risk factors such as hypertension and is associated with other unhealthy behaviors. Hypertension and age are both significant risk factors; the risk of heart disease increases with age and with sustained high blood pressure.

Choice C Reason:

Alcohol consumption in excess can lead to high blood pressure, heart failure, or stroke. Obesity, diabetes, and stress are all risk factors as previously mentioned. Hyperlipidemia is also a modifiable risk factor that can be managed through diet, exercise, and medication.

Choice D Reason:

Personality type itself is not a direct risk factor for heart disease, but certain personality traits can lead to stress, which is a risk factor. Hyperlipidemia, diabetes, and smoking are all direct risk factors for heart disease as they contribute to the development of cardiovascular conditions.

A. Blood pressure of 120/80 mmHg. B. Serum potassium of 5.5 mEq/L. C. Heart rate of 80 beats per minute. D. Respiration rate of 16 breaths per minute.

Correct Answer is B

Explanation

Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.

Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.

Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

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A client was admitted to the emergency department with slurred speech and impaired motor coordination. The blood alcohol level is over 300 mg/dL. The physician orders thiamine for the client. The nurse understands that the physician ordered thiamine to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client's major risk factors for heart disease, which of the following should the nurse include in the history?

Correct Answer is A

Explanation

A client is prescribed lisinopril 20 mg PO daily for the treatment of hypertension. Which finding would alert the nurse that a side effect of the medication has occurred?

Correct Answer is B

Explanation

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