A nurse is caring for a client who has Wernicke-Korsakoff psychosis as a result of chronic alcohol use disorder. Which of the following interventions should the nurse anticipate?
Monitoring for the presence of esophageal varices
Placing the client in protective isolation
Laboratory analysis of cardiac enzymes
Administration of thiamine
The Correct Answer is D
D. Wernicke-Korsakoff psychosis is a neurological disorder caused by thiamine (vitamin B1) deficiency, often resulting from chronic alcohol use disorder. Thiamine deficiency can lead to significant neurological impairments, including confusion, ataxia, and memory deficits characteristic of Wernicke's encephalopathy and Korsakoff's psychosis.
The primary intervention for Wernicke-Korsakoff psychosis is the administration of thiamine supplementation. Thiamine replacement therapy is essential to prevent further neurological deterioration and to potentially reverse some of the cognitive deficits associated with the disorder.
The other options are not directly related to Wernicke-Korsakoff psychosis:
A. Monitoring for the presence of esophageal varices is more relevant to complications of chronic liver disease, such as cirrhosis, commonly seen in individuals with alcohol use disorder, but not specific to Wernicke-Korsakoff psychosis.
B. Placing the client in protective isolation is not indicated for Wernicke-Korsakoff psychosis. Protective isolation is typically used for clients with compromised immune systems to reduce the risk of infection.
C. Laboratory analysis of cardiac enzymes is typically performed to assess for myocardial injury or infarction, which is not directly associated with Wernicke-Korsakoff psychosis.
Nursing Test Bank
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Related Questions
Correct Answer is ["2"]
Explanation
To calculate the volume of chlorpromazine to administer per dose, we'll use the formula:
Volume(mL)=Totaldoseneeded(mg)/Concentrationofthemedication(mg/mL)
Given: Total dose needed per dose = 50 mg
Concentration of chlorpromazine injection = 25 mg/mL
Substituting the given values into the formula:
Volume(mL)=50 mg/25 mg/mL
Volume(mL)=2 mL
Rounded to the nearest whole number, the nurse should administer 2 mL of chlorpromazine per dose.
Correct Answer is B
Explanation
A. Dilute the medication with sterile water before injecting: Phenytoin should not be diluted before administration because it may cause precipitation or crystallization of the drug, leading to potential adverse effects such as tissue irritation or embolism.
B. Administer the medication over 1 min: Phenytoin should be administered slowly over 1 to 2 minutes to reduce the risk of adverse effects such as hypotension or cardiac arrhythmias. Rapid infusion can lead to cardiovascular collapse.
C. Slow the injection if the medication crystallizes: If the medication crystallizes, the nurse should stop the injection immediately and flush the IV line with normal saline. However, preventing crystallization by administering the medication slowly over the recommended time is preferable.
D. Follow the IV injection with sterile water: Following the IV injection with sterile water is not a standard practice for administering phenytoin. Instead, the nurse should follow institutional guidelines for flushing the IV line after medication administration, typically with normal saline.
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