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 ["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 ["8"]
Explanation
To calculate the flow rate in drops per minute (gtt/min), we first need to find the total number of drops (gtt) that will be infused over 3 hours and then divide by the total infusion time in minutes.
Given: Volume to infuse = 150 mL
Infusion time = 3 hours
Drop factor = 10 gtt/mL
First, let's find the total number of drops for the entire infusion:
Total drops = Volume × Drop factor
Total drops = 150 mL × 10 gtt/mL = 1500 drops
Now, let's find the infusion time in minutes: Infusion time (in minutes) = 3 hours × 60 minutes/hour = 180 minutes
Finally, let's calculate the flow rate:
Flow rate (gtt/min) = Total drops / Infusion time
Flow rate = 1500 drops / 180 minutes ≈ 8.33 gtt/min
Rounded to the nearest whole number, the nurse should set the manual IV infusion to deliver approximately 8 gtt/min.
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