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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Akathisia: Akathisia is characterized by restlessness and an inability to sit still. While it can be a side effect of antipsychotic medications like haloperidol, it does not present with fever, hypertension, and muscle rigidity, as described in the scenario.

B. Neuroleptic malignant syndrome (NMS): NMS is a potentially life-threatening condition associated with antipsychotic medications like haloperidol. It is characterized by hyperthermia, autonomic dysfunction (e.g., hypertension), altered mental status, and severe muscle rigidity. The client's symptoms of fever, elevated blood pressure, and muscle rigidity are consistent with NMS.

C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive movements of the face, tongue, and other body parts. It is a long-term side effect of antipsychotic medications and typically develops after prolonged use, unlike the acute onset seen in the scenario.

D. Agranulocytosis: Agranulocytosis is a rare but serious side effect of antipsychotic medications, characterized by a severe reduction in white blood cell count, leading to an increased risk of infection. The symptoms described in the scenario are not consistent with agranulocytosis.

A. Dystonia B. Tardive dyskinesia C. Parkinsonism D. Akathisia

Correct Answer is B

Explanation

A. Dystonia - Dystonia presents as sustained or intermittent muscle contractions causing abnormal, often repetitive, movements or postures. It is an acute extrapyramidal side effect of antipsychotic medications like chlorpromazine but typically manifests as sudden-onset muscle spasms rather than involuntary movements of the tongue and face.

B. Tardive dyskinesia - Tardive dyskinesia is a late-appearing movement disorder characterized by involuntary, repetitive movements of the face, tongue, and limbs. It is associated with long-term use of antipsychotic medications like chlorpromazine and typically develops after months to years of treatment.

C. Parkinsonism - Parkinsonism resembles Parkinson's disease and is characterized by symptoms such as tremor, rigidity, bradykinesia, and postural instability. While antipsychotic medications can cause Parkinsonism as an adverse effect, it usually presents with symptoms different from those described in the scenario.

D. Akathisia - Akathisia is characterized by an inner feeling of restlessness and the urge to move, often accompanied by pacing and inability to sit still. It is an acute extrapyramidal side effect of antipsychotic medications but does not manifest as involuntary movements of the tongue and face as described in the scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5* C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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