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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: Gastric lavage may be considered, but the priority is to address respiratory depression. Naloxone administration is more immediate.

Choice B rationale: Renal dialysis is not indicated for the overdose of methadone and benzodiazepines. Addressing respiratory depression is the priority.

Choice C rationale: Nebulizing with albuterol is not the appropriate intervention for respiratory depression due to drug overdose. Naloxone administration is more critical. Choice D rationale: Administration of naloxone is the priority for this client with respiratory depression due to the potential opioid overdose (methadone). Naloxone is an opioid antagonist that can reverse opioid-induced respiratory depression.

A. Walt for the client to respond. B. Ask if the client heard the question. C. Ask a different question. D. Return at a later time to talk.

Correct Answer is A

Explanation

Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.

Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.

Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.

Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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