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: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.

Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.

Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.

Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.

A. "Have you had a bad experience related to unlocked doors?" B. "What are your thoughts when you are checking the locks?" C. "Repeating the same behavior helps you to diminish your anxiety." D. "Feelings of being driven to do something are related to anxiety."

Correct Answer is B

Explanation

Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).

Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.

Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.

Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.

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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?

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Correct Answer is D

Explanation

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

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