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 B
Explanation
A. "It doesn't really matter what time you take your medications as long as you don't skip any doses": This statement is incorrect because adherence to the prescribed dosing schedule is crucial for the effectiveness of medications. Inconsistent timing of doses can lead to suboptimal therapeutic outcomes or potential adverse effects.
B. "Let's work together to devise a time schedule that is convenient for you on a daily basis": This is the most appropriate instruction. Collaborating with the client to establish a medication schedule that aligns with their daily routine increases the likelihood of adherence. It promotes patient autonomy and empowers the client to take ownership of their medication regimen.
C. "You really shouldn't change the schedule we established here in the facility": While maintaining consistency in medication administration times is important, rigidly adhering to a schedule established during the facility stay may not always be feasible or practical for the client at home. Flexibility in adjusting the schedule to fit the client's lifestyle is essential for long-term adherence.
D. "We'll have to talk to your provider about switching to an alternative schedule": Switching to an alternative schedule should be considered only if the current schedule is not feasible for the client or if it compromises medication adherence. However, exploring options for adapting the existing schedule to better suit the client's needs should be attempted first before considering a switch.
Correct Answer is ["50"]
Explanation
To calculate the volume of phenytoin oral solution to administer per dose, we'll use the formula:
Volume(mL)=Totaldoseneeded(mg)/Concentrationofthemedication(mg/mL)
Given: Total dose needed per dose = 250 mg
Concentration of phenytoin oral solution = 25 mg/5 mL
(which simplifies to 5 mg/mL)
Substituting the given values into the formula:
Volume(mL)=250 mg/5 mg/mL
Volume(mL)=50 mL
Rounded to the nearest whole number, the nurse should administer 50 mL of phenytoin oral solution per dose.
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