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 D

Explanation

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

A. Eat high-protein foods to achieve ideal body weight. B. Avoid acetylsalicylic acid-containing medications. C. Wrap joints with an elastic bandage when swollen. D. Support joints in an extended position while resting.

Correct Answer is B

Explanation

Choice A reason: Eating high-protein foods to achieve ideal body weight is generally a healthy practice, but it is not directly related to the management of the client's current condition involving pain in the toe.

Choice B reason: Patients with gouty arthritis should avoid acetylsalicylic acid (aspirin) as it can lead to an increase in uric acid levels, potentially exacerbating gout attacks. Instead, medications that do not affect uric acid levels should be used for pain relief.

Choice C reason: Wrapping joints with an elastic bandage can provide support and reduce swelling, but it is not the primary intervention for sudden pain in the toe following an appendectomy, especially when the patient has a history of gouty arthritis.

Choice D reason: Supporting joints in an extended position while resting can provide comfort and may prevent stiffness, but it does not address the acute management of gouty arthritis or diabetic complications that could be causing toe pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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