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. The client demonstrated an allergic response to the medication: While allergic reactions to disulfiram can occur, severe nausea and vomiting after taking the medication are more likely due to its interaction with alcohol rather than an allergic response.

B. The client consumed alcohol while taking the medication: Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. Severe nausea and vomiting are common adverse effects of consuming alcohol while on disulfiram.

C. The client took an overdose of the medication: An overdose of disulfiram could potentially lead to severe adverse effects, but nausea and vomiting alone are not typically indicative of an overdose.

D. The client experienced a common side effect of the medication: While nausea and vomiting are common side effects of disulfiram, they are typically experienced in response to alcohol consumption rather than as direct effects of the medication itself.

A. Tap the top of the ampule. place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body. B. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body. C. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion. D. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side.

Correct Answer is A

Explanation

When opening a glass ampule, it's essential to use the correct technique to prevent injury and ensure sterility. Here's the rationale for each option:

A. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body: This technique is correct. Tapping the top of the ampule helps dislodge any medication that may be trapped in the neck. Placing a sterile gauze pad around the neck provides a barrier to protect against injury from glass shards. Breaking off the top by bending it toward the body helps prevent spillage of the medication.

B. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body: Tapping the bottom of the ampule is unnecessary and may increase the risk of breakage. Breaking off the bottom with a forward motion away from the body is not the recommended technique for opening a glass ampule.

C. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion: This technique does not involve the use of a gauze pad to protect against injury, which is essential for safe medication administration.

D. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side: Breaking off the neck with a single snap to the right side is not a recommended technique. Additionally, using sterile gloves alone may not provide sufficient protection against injury from glass shards.

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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

Correct Answer is B

Explanation

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

Correct Answer is A

Explanation

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