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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bleeding: While haloperidol can cause side effects such as orthostatic hypotension and sedation, it is not typically associated with bleeding as a common adverse effect.
B. Pancreatitis: Pancreatitis is not a common adverse effect of haloperidol. However, it can cause gastrointestinal side effects such as constipation, nausea, and vomiting.
C. Cataracts: Haloperidol is not known to cause cataracts. However, long-term use of antipsychotic medications, including haloperidol, may increase the risk of developing metabolic side effects such as weight gain, dyslipidemia, and hyperglycemia, which can contribute to conditions like diabetes and potentially increase the risk of cataracts.
D. Dysrhythmias: Haloperidol can prolong the QT interval on an electrocardiogram (ECG), leading to an increased risk of dysrhythmias, including torsades de pointes. This risk is particularly important in clients with preexisting cardiovascular conditions or those taking other medications that can prolong the QT interval. Therefore, nurses should monitor clients receiving haloperidol for signs of dysrhythmias, including palpitations, dizziness, and syncope, and promptly report any abnormalities to the healthcare provider.
Correct Answer is ["B","C","D","E"]
Explanation
Answer: (B, C, D, E)
Rationale:
A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.
B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.
C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.
D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.
E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.
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