A client diagnosed with psychosis arrives at the emergency department and is communicating non-verbally through gesture-like actions. To encourage the client's verbal communication, which question would be best for the nurse to ask?

"Tell me about what's been bothering you lately."

"How did you get to the hospital?"

"Are you in pain?"

"What happened before you came here?"

Answer and Explanation

The Correct Answer is C

A. Asking the client to describe what has been bothering them is open-ended and abstract, which may be overwhelming or difficult for a client experiencing psychosis and communicating primarily non-verbally. This approach may not effectively elicit immediate verbal responses.

B. Asking how the client got to the hospital is factual but may not be relevant to the client’s current emotional state or comfort level. It does not directly encourage verbalization of needs or feelings.

C. Asking "Are you in pain?" is a direct, simple, and concrete question that focuses on the client’s immediate experience. Clients with psychosis may respond more easily to clear, short, and specific questions. This type of question encourages verbal communication while acknowledging the client’s current condition and needs.

D. Asking "What happened before you came here?" is somewhat open-ended and may require abstract thinking or memory recall, which can be challenging for a client in acute psychosis and may not facilitate immediate verbal communication.

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Correct Answer is A

Explanation

A. A reduced level of pain indicates the medication is effective. Within several days of starting therapy, clients may notice a decrease in pain intensity, improved sleep, or increased ability to perform daily activities. This is the primary therapeutic goal of pregabalin. Monitoring pain levels using a standardized pain scale helps determine the effectiveness and need for dosage adjustments.

B. Improved visual acuity is unrelated to pregabalin. Visual changes in clients with diabetes are typically associated with diabetic retinopathy or cataracts. Pregabalin has no effect on eye health or vision.

C. Full volume of pedal pulses reflects peripheral circulation and arterial blood flow, which is influenced by vascular status rather than neuropathic pain. Pregabalin does not improve circulation or affect pulse volume.

D. Granulating tissue in a foot ulcer indicates wound healing but is not a direct effect of pregabalin. While pain relief might help the client engage in self-care or mobility, promoting tissue repair involves glycemic control, infection management, and wound care interventions, not neuropathic pain medications.

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

Correct Answer is D

Explanation

A. Right lower abdominal pain is not associated with Wernicke’s syndrome. This finding would suggest a gastrointestinal issue, such as appendicitis, and is unrelated to the neurological effects of thiamine deficiency.

B. Peripheral neuropathy can occur with chronic thiamine deficiency, but it is more commonly associated with beriberi. While it may be present, it is not the hallmark feature used to guide immediate care planning for Wernicke’s syndrome.

C. Depression may be seen in chronic alcohol use or malnutrition, but it is not a defining or urgent feature of Wernicke’s syndrome. Addressing depression is important but secondary to preventing acute neurological deterioration.

D. Confusion is a key clinical feature of Wernicke’s syndrome and reflects the acute neurocognitive effects of thiamine deficiency. It is part of the classic triad (confusion, ataxia, ophthalmoplegia) and is critical for developing the care plan. Immediate recognition and treatment with thiamine are essential to prevent progression to Wernicke-Korsakoff syndrome, which can cause irreversible cognitive impairment.

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A client diagnosed with psychosis arrives at the emergency department and is communicating non-verbally through gesture-like actions. To encourage the client's verbal communication, which question would be best for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

Correct Answer is A

Explanation

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

Correct Answer is D

Explanation

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