A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Individual addiction counseling.

Initiate disulfiram teaching.

Thiamine administration.

Nutrition referral.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.

Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.

Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.

Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale: Involving her in group therapy may be premature, as the client has just started to exhibit changes in behavior. Continuous observation is necessary to assess the nature and sustainability of these changes.

Choice B rationale: Praising her for the new behavior is positive, but continuous observation is essential to monitor for any signs of escalating or problematic behavior.

Choice C rationale: Observing her actions continuously is the most appropriate action at this point. The nurse needs to monitor the client closely to assess the nature of the changes, ensuring they are not indicative of increased agitation or potential harm.

Choice D rationale: Offering her a choice of activities may be appropriate once the nurse has a better understanding of the clien's current state. However, continuous observation is the priority.

A. The nurse is stating disapproval of the statement. B. Silence is reflecting the client's sadness. C. Silence allows the client to reflect on what was said. D. The nurse is respecting the client's loss.

Correct Answer is C

Explanation

Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.

Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.

Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.

Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

Correct Answer is C

Explanation

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

Correct Answer is C

Explanation

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.