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 ["A","D","E"]
Explanation
Tardive dyskinesia (TD) is a potential adverse effect associated with long-term use of antipsychotic medications like haloperidol. It manifests as involuntary, repetitive movements, primarily involving the face, mouth, and tongue. The nurse should suspect tardive dyskinesia when observing the following manifestations:
A. Involuntary pelvic rocking and hip thrusting movements: These movements are characteristic of tardive dyskinesia and indicate abnormal involuntary motor activity.
B. Urinary retention and constipation: These are not typical manifestations of tardive dyskinesia. Urinary retention and constipation can be side effects of anticholinergic medications but are not associated with tardive dyskinesia.
C. Fine hand tremors and pill rolling: These manifestations are more characteristic of parkinsonism, which can be a side effect of antipsychotic medications but is distinct from tardive dyskinesia.
D. Tongue thrusting and lip smacking: These are classic manifestations of tardive dyskinesia and indicate abnormal involuntary movements of the tongue and lips.
E. Facial grimacing and eye blinking: These are also common manifestations of tardive dyskinesia, involving involuntary movements of the face, including grimacing and blinking of the eyes.
Correct Answer is ["75"]
Explanation
To calculate the infusion rate in mL/hr for total parenteral nutrition (TPN) we divide the total volume by the total infusion time.
Given: Total volume of TPN = 1800 mL Total infusion time = 24 hours
Infusion rate (mL/hr) = Total volume / Total infusion time
Substituting the given values: Infusion rate = 1800 mL / 24 hr ≈ 75 mL/hr
Rounded to the nearest whole number, the nurse should set the IV pump to deliver approximately 75 mL/hr of TPN.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.