The nurse is caring for a client with alcohol use disorder. Which of the following nursing interventions is appropriate for a client to prevent Korsakoff’s syndrome?

Encouraging the client to consume foods high in vitamin B1.

Implementing strict bed rest to conserve energy.

Restricting fluid intake to prevent water intoxication.

Administering thiamine supplements as prescribed.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Encouraging the client to consume foods high in vitamin B1 (thiamine) is beneficial, but it may not be sufficient alone to prevent Korsakoff’s syndrome in individuals with alcohol use disorder. Thiamine is crucial for brain function, and its deficiency can lead to Wernicke-Korsakoff syndrome. However, due to malabsorption issues common in alcohol use disorder, dietary intake alone might not meet the necessary thiamine levels.

Choice B Reason: Implementing strict bed rest to conserve energy is not directly related to preventing Korsakoff’s syndrome. While rest is important for overall health, it does not address the thiamine deficiency that leads to this condition. Korsakoff’s syndrome is primarily caused by a lack of thiamine, and conserving energy does not mitigate this deficiency.

Choice C Reason: Restricting fluid intake to prevent water intoxication is not relevant to preventing Korsakoff’s syndrome. Water intoxication is a separate issue and does not address the thiamine deficiency that causes Korsakoff’s syndrome. Proper hydration is important, but it does not prevent the neurological damage associated with thiamine deficiency.

Choice D Reason: Administering thiamine supplements as prescribed is the most appropriate intervention to prevent Korsakoff’s syndrome. Thiamine supplementation is crucial for individuals with alcohol use disorder because their bodies often cannot absorb enough thiamine from food alone. Thiamine is essential for brain function, and its deficiency can lead to severe neurological damage. Administering supplements ensures that the client receives an adequate amount of this vital nutrient.

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Correct Answer is ["B","D","E"]

Explanation

b. +3 edema to the mid-calf

d. Irregular wound borders

e. Minimal serous drainage

Explanation of Choices

Choice A Reason: Distinct Wound Borders to Plantar Aspect of Foot

Venous ulcers typically present with irregular wound borders rather than distinct ones. They are usually found on the lower legs, particularly around the medial malleolus (inner ankle), rather than the plantar aspect of the foot. The plantar aspect of the foot is more commonly associated with diabetic ulcers or pressure sores. Therefore, distinct wound borders to the plantar aspect of the foot are not indicative of a venous ulcer.

Choice B Reason: +3 Edema to the Mid-Calf

Edema, or swelling, is a common finding in patients with venous ulcers. Venous insufficiency leads to increased pressure in the veins, causing fluid to leak into the surrounding tissues, resulting in edema. The presence of +3 edema (a significant level of swelling) in the mid-calf is a strong indicator of venous insufficiency and, consequently, venous ulcers. This finding supports the diagnosis of a venous ulcer.

Choice C Reason: Patient Reports 9 (0-10) Pain Scale to Area

While pain can be associated with venous ulcers, it is not a definitive diagnostic criterion. Pain levels can vary widely among individuals with venous ulcers, and some may experience minimal discomfort. A pain scale rating of 9 out of 10 indicates severe pain, which could be due to various conditions, not specifically venous ulcers. Therefore, this finding alone is not sufficient to suspect a venous ulcer.

Choice D Reason: Irregular Wound Borders

Venous ulcers are characterized by their irregular wound borders. Unlike arterial ulcers, which have well-defined edges, venous ulcers tend to have uneven, irregular borders. This is due to the chronic nature of venous insufficiency and the ongoing damage to the skin and underlying tissues. The presence of irregular wound borders is a key indicator of a venous ulcer.

Choice E Reason: Minimal Serous Drainage

Venous ulcers often produce serous drainage, which is a clear to pale yellow fluid. The amount of drainage can vary, but minimal serous drainage is a common finding. This type of drainage is due to the chronic inflammation and fluid leakage associated with venous insufficiency. Therefore, minimal serous drainage is consistent with the presence of a venous ulcer.

A. Assist the client to identify the triggering situation and choose a coping strategy. B. Send the client to the crisis intervention unit for 23 hours of observation. C. Restrain the client to prevent self-harm. D. Advise the client to take an anxiolytic to decrease their anxiety level.

Correct Answer is A

Explanation

Choice A Reason: Assist the client to identify the triggering situation and choose a coping strategy

This is the correct answer. Assisting the client to identify the triggering situation and choose a coping strategy is a therapeutic approach that empowers the client to understand and manage their emotions. This intervention helps the client develop skills to cope with distressing feelings and reduces the likelihood of self-harm. It is essential to address the underlying issues and provide support in a constructive manner.

Choice B Reason: Send the client to the crisis intervention unit for 23 hours of observation

While sending the client to a crisis intervention unit may be necessary in some cases, it is not the first step. Immediate therapeutic intervention to help the client understand and manage their emotions is crucial. Observation alone does not address the underlying issues or provide the client with coping mechanisms.

Choice C Reason: Restrain the client to prevent self-harm

Restraint should be a last resort and only used when there is an immediate risk of harm that cannot be managed through other means. It is important to first attempt less restrictive interventions that help the client manage their emotions and behaviors.

Choice D Reason: Advise the client to take an anxiolytic to decrease their anxiety level

While medication can be part of the treatment plan, it should not be the first intervention. Addressing the client’s immediate emotional needs and helping them develop coping strategies is crucial. Medication can be considered as part of a comprehensive treatment plan but should not replace therapeutic interventions.

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The nurse is caring for a client with alcohol use disorder. Which of the following nursing interventions is appropriate for a client to prevent Korsakoff’s syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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