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. 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.

A. Documents medication administration prior to administering it. B. Verifies the medication against the prescription and medication label. C. Checks the provider's orders and confirmed dosage in a medication reference guide. D. Scans the bar code on the medication administration record and the client's arm band

Correct Answer is A

Explanation

A. Documents medication administration prior to administering it: Documenting medication administration before actually administering it is incorrect and can lead to errors in documentation. The nurse should document medication administration after ensuring the medication is given to the client.

B. Verifies the medication against the prescription and medication label: This is a correct action. The nurse should verify the medication against the prescription and medication label to ensure accuracy before administering it.

C. Checks the provider's orders and confirmed dosage in a medication reference guide: This is a correct action. The nurse should check the provider's orders and confirm the dosage in a reliable medication reference guide to ensure accuracy before administering the medication.

D. Scans the barcode on the medication administration record and the client's armband: This is a correct action. Scanning the barcode on the medication administration record and the client's armband helps ensure the "Five Rights" of medication administration: right patient, right medication, right dose, right route, and right time.

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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 is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

Correct Answer is B

Explanation

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Correct Answer is A

Explanation

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