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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Tell me more about what unpleasant effects you have been experiencing
Explanation of Choices
Choice A Reason: Tell Me More About What Unpleasant Effects You Have Been Experiencing
This response is the most appropriate because it opens a dialogue between the nurse, the client, and the parent. Understanding the specific side effects the client is experiencing allows the nurse to gather detailed information, which is crucial for assessing the situation accurately. This approach shows empathy and concern for the client’s well-being and can help identify whether the side effects are manageable or if an alternative treatment plan is needed. It also ensures that the client feels heard and supported.
Choice B Reason: Stop Taking the Medication Immediately
Advising the client to stop taking the medication immediately is not appropriate without a thorough assessment and consultation with the prescribing physician. Abruptly discontinuing ADHD medication can lead to withdrawal symptoms and a resurgence of ADHD symptoms, which can negatively impact the client’s daily functioning and overall health. Medication changes should always be made under medical supervision to ensure safety and effectiveness.
Choice C Reason: I’ll Get the Physician to Discuss This Situation
While involving the physician is an important step, this response alone does not address the immediate concerns of the client and parent. It is essential for the nurse to first understand the specific issues before referring to the physician. This ensures that the physician has all the necessary information to make an informed decision about the client’s treatment plan. Additionally, this response may come across as dismissive if not coupled with an initial assessment by the nurse.
Choice D Reason: It’s Important to Take the Medication as Prescribed
While it is true that taking medication as prescribed is important, this response does not acknowledge the client’s and parent’s concerns about side effects. It may come across as dismissive and could damage the trust between the client, parent, and healthcare provider. Addressing the side effects and exploring possible solutions or alternatives is crucial for maintaining adherence to the treatment plan and ensuring the client’s well-being.
Correct Answer is C
Explanation
Choice A Reason: Anorexia Nervosa
Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight and a distorted body image, leading to restricted food intake and excessive weight loss. Individuals with anorexia nervosa often have a relentless pursuit of thinness and may engage in extreme dieting, excessive exercise, and other behaviors to lose weight. While eliminating specific foods can be a part of anorexia nervosa, the primary focus is on weight loss and body image rather than the purity or healthiness of the food.
Choice B Reason: Rumination Disorder
Rumination disorder involves the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is more common in infants and individuals with developmental disabilities but can occur in people of all ages. The behavior is typically involuntary and not related to concerns about food purity or healthiness. Therefore, it does not align with the client’s report of eliminating specific foods to “eat clean.”
Choice C Reason: Orthorexia
Orthorexia is an eating disorder characterized by an obsession with eating foods that one considers healthy or pure. Individuals with orthorexia may eliminate entire food groups, such as sugars, carbohydrates, or dairy, in their quest to maintain a “clean” diet6. This condition can lead to malnutrition and social isolation due to the restrictive nature of the diet. The client’s report of eliminating specific foods to “eat clean” is a clear indication of orthorexia.
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