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 D

Explanation

d. When the client last had a drink of alcohol

Explanation of Choices

Choice A Reason: If the Client Has a History of Addictive Behaviors

Assessing whether the client has a history of addictive behaviors is important as it provides insight into the client’s overall pattern of substance use and potential risk for relapse. However, while this information is valuable for developing a comprehensive treatment plan, it is not the most immediate concern during the initial admission assessment. The primary focus should be on identifying any immediate risks or needs, such as the potential for alcohol withdrawal.

Choice B Reason: Whether the Client Has Had Previous Rehabilitation for Alcoholism

Knowing whether the client has had previous rehabilitation for alcoholism can help the nurse understand the client’s treatment history and any previous interventions that may have been effective or ineffective. This information is useful for planning ongoing care and support. However, it is not the most critical factor to assess during the initial admission, as it does not directly address the client’s current physical and mental state.

Choice C Reason: Their Previous and Current Coping Skills

Evaluating the client’s previous and current coping skills is essential for understanding how they manage stress and triggers related to their alcoholism. This assessment can inform the development of personalized coping strategies and support mechanisms. Nonetheless, while important for long-term treatment planning, it is not the most urgent factor to assess during the initial admission.

Choice D Reason: When the Client Last Had a Drink of Alcohol

Determining when the client last had a drink of alcohol is the most important factor to assess during the initial admission. This information is crucial for predicting the onset of alcohol withdrawal symptoms, which can begin as early as 4 to 6 hours after the last drink. Early identification of potential withdrawal allows the healthcare team to implement appropriate monitoring and interventions to manage withdrawal symptoms and prevent complications. Alcohol withdrawal can be life-threatening if not properly managed, making this assessment a top priority.

A. The patient’s partner’s act of sending flowers is an example of undoing. B. The patient and partner are in the honeymoon phase of intimate partner violence. C. The patient has a submissive personality and depression. D. Since the injuries have caused hospitalization, the patient will end the relationship. E. The partner may be trying to manipulate the staff by buying pizza.

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

Explanation

The correct answer is a, b, and e.

Choice A Reason:

The patient’s partner’s act of sending flowers is an example of undoing. Undoing is a defense mechanism where a person tries to cancel out or remove an unhealthy, destructive, or otherwise threatening thought or action by engaging in contrary behavior. In this case, the partner is attempting to make amends for the abuse by sending flowers, which is a common tactic used by abusers to mitigate their guilt and manipulate the victim into forgiving them.

Choice B Reason:

The patient and partner are in the honeymoon phase of intimate partner violence. The cycle of abuse in intimate partner violence typically includes a honeymoon phase, where the abuser may apologize, show remorse, and promise to change. This phase often involves gestures of affection and kindness, such as sending flowers or gifts, to win back the victim’s trust and prevent them from leaving.

Choice C Reason:

The patient has a submissive personality and depression. While it is possible that the patient may have a submissive personality and depression, this conclusion cannot be definitively made based on the given scenario alone. Submissive personality traits and depression are complex and require thorough psychological evaluation to diagnose accurately.

Choice D Reason:

Since the injuries have caused hospitalization, the patient will end the relationship. This conclusion is not necessarily accurate. Victims of intimate partner violence often face significant psychological, emotional, and practical barriers to leaving an abusive relationship, even after severe incidents that result in hospitalization. The decision to leave an abusive relationship is influenced by various factors, including fear, financial dependence, emotional attachment, and lack of support.

Choice E Reason:

The partner may be trying to manipulate the staff by buying pizza. Manipulative behavior is common in abusive relationships. By buying pizza for the staff, the partner may be attempting to create a favorable impression and gain sympathy, which can influence the staff’s perception of the situation and potentially affect their support for the patient.

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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

What is the most important factor for the nurse to assess when doing an admission assessment of a client with a history of alcoholism?

Correct Answer is D

Explanation

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

Explanation

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