A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?
Individual addiction counseling.
Initiate disulfiram teaching.
Thiamine administration.
Nutrition referral.
The Correct Answer is C
Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.
Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.
Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.
Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.
Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.
Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.
Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.
Correct Answer is C
Explanation
Choice A rationale: Fear of large dogs may or may not be related to schizophrenia; other information is needed to determine its significance.
Choice B rationale: Decreased attention to detail is a symptom that may be observed in schizophrenia, but it is not the primary behavior to notify the healthcare provider.
Choice C rationale: Social withdrawal is a concerning behavior in schizophrenia that may indicate worsening symptoms and should be reported to the healthcare provider.
Choice D rationale: Changes in appetite are important to monitor but may not be the primary indicator of a worsening condition in schizophrenia.
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