Patient data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan.

Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema.

Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.

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Correct Answer is A

Explanation

A. Administering an IV analgesic is the most important intervention for managing the client's severe abdominal incisional pain. Prompt pain management is essential for the client's comfort and well-being, and severe pain can lead to increased physiological stress responses, such as
tachycardia and hypertension.
B. Providing a pillow for splinting may help alleviate pain to some extent, but it does not address the underlying cause of the severe abdominal incisional pain. Pain management with analgesics is the priority.
C. Assessing the IV site for patency is important for ensuring the delivery of medications, but it is not the most urgent intervention in this situation where the client is experiencing severe pain.
D. Placing the client in a high-Fowler's position may help alleviate some discomfort, but it is not the most important intervention for managing the client's severe abdominal incisional pain.
Administering analgesics should be prioritized.

A. Depression. B. Right lower abdominal pain. C. Peripheral neuropathy. D. Confusion.

Correct Answer is D

Explanation

A. Depression: While depression may occur in some individuals with Wernicke's syndrome, confusion is the primary assessment finding associated with this condition.
B. Right lower abdominal pain: Abdominal pain is not a characteristic symptom of Wernicke's syndrome. Confusion, ophthalmoplegia, and ataxia are more common.
C. Peripheral neuropathy: While peripheral neuropathy may occur in some neurological conditions, it is not specific to Wernicke's syndrome, which primarily presents with confusion, ophthalmoplegia, and ataxia.
D. Confusion: Confusion is a hallmark symptom of Wernicke's syndrome and should be a primary focus of assessment and care planning for this condition.

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Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

Correct Answer is D

Explanation

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Patient data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.