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

Right lower abdominal pain.

Peripheral neuropathy.

Confusion.

Depression.

Answer and Explanation

The Correct Answer is C

Choice A reason: Right lower abdominal pain is not typically associated with Wernicke's syndrome and would likely indicate a different issue.

Choice B reason: Peripheral neuropathy can be a symptom of Wernicke's syndrome, but it is not as central to the condition as confusion, which is a hallmark sign.

Choice C reason: Confusion is a primary symptom of Wernicke's syndrome and should be used in planning the client's care, as it indicates acute encephalopathy and the need for immediate treatment with thiamine.

Choice D reason: Depression may be present in clients with Wernicke's syndrome, but it is not a primary assessment finding used to plan care for the acute stage of the condition.

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Correct Answer is A,B,C,D,E

Explanation

Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit.

Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation.

Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action.

Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure.

Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.

A. Shaking that changes the child's handwriting legibility. B. Thirst and frequent requests for bathroom breaks. C. Refusal to complete written homework assignments. D. Bruises on both knees after the weekend. E. Sunburn with blisters on the face, arms, and hands.

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

Explanation

Choice A reason: Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention.

Choice B reason: Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.

Choice C reason: While refusal to complete homework could be related to behavioral or social issues, it is not typically a medical concern that requires the school nurse's intervention unless accompanied by other signs of distress or health problems.

Choice D reason: Bruises could be common in children due to their active nature, especially after a weekend. However, unless there is a pattern or other concerning signs of abuse or a medical condition, bruises alone may not necessitate a referral to the school nurse.

Choice E reason: Sunburn with blisters is a sign of a second-degree burn, which can be serious, especially in children. It is important for teachers to report this to the school nurse so that the child can receive proper care and parents can be advised on treatment and prevention.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A,B,C,D,E

Explanation

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply.

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

Explanation

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