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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A broad-spectrum antibiotic is not indicated for Addison's disease unless there is a concurrent bacterial infection.
Choice B reason: Regular insulin is used to lower blood glucose levels, which are not elevated in this case.
Choice C reason: Potassium chloride would not be prescribed as the potassium level is already high.
Choice D reason: Hydrocortisone is anticipated because it is a corticosteroid replacement therapy, which is essential for a patient with Addison's disease experiencing an adrenal crisis.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk.
Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments.
Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition.
Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus.
Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.
Normal Ranges:
- BMI: 18.5 to 24.9 kg/m² (normal)
- HDL (High-Density Lipoprotein): Greater than 45 mg/dL (Greater than 1.15 mmol/L)
- LDL (Low-Density Lipoprotein): Less than 130 mg/dL (Less than 3.4 mmol/L)
- Fasting Blood Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)
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