The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement?

"My condition is a degenerative brain disorder caused by nutrient deficiency."

"There is swelling of my brain that is caused by alcohol consumption."

"The inability of my liver to metabolize the alcohol caused this condition."

"Toxins from the alcohol I drank have caused my brain to swell."

Answer and Explanation

The Correct Answer is A

A. "My condition is a degenerative brain disorder caused by nutrient deficiency." Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency, which is often due to chronic alcoholism. The condition is associated with neurological damage from this nutrient deficiency, making this statement accurate.

B. "There is swelling of my brain that is caused by alcohol consumption." Wernicke encephalopathy is not characterized by brain swelling but by neurological damage due to thiamine deficiency.

C. "The inability of my liver to metabolize the alcohol caused this condition." While liver dysfunction can be associated with alcohol use, Wernicke encephalopathy is specifically due to thiamine deficiency, not liver metabolism issues.

D. "Toxins from the alcohol I drank have caused my brain to swell." This statement is incorrect as Wernicke encephalopathy is related to thiamine deficiency rather than brain swelling from alcohol toxins.

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Correct Answer is C

Explanation

A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).

B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.

C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.

D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.

A. Disturbed body image related to depression B. Imbalanced nutrition: Less than body requirements related to depression C. Hygiene self-care deficit related to depression D. Risk for self-directed violence related to depression

Correct Answer is D

Explanation

A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.

B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.

C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.

D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.

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The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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