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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Headaches can be associated with various factors and are not specific to depression.
Choice B rationale: Back pain can have multiple causes and is not specific to depression. Choice C rationale: Dizziness may have various causes and is not specific to depression. Choice D rationale: Excessive tiredness (fatigue) is a common symptom of depression and often associated with the overall low energy levels experienced by individuals with depressive disorders.
Correct Answer is B
Explanation
A. Referral to a social worker may be beneficial for long-term support and resources. However, it does not address the client’s immediate sense of fear and need for safety.
B. Offering a safe place to relax is the priority because the client is expressing fear and possible threat from a stalker. Ensuring immediate safety and reducing anxiety aligns with the priority principle of protecting the client from harm.
C. Arranging an interview with the healthcare provider is important for further evaluation and planning. However, it does not address the client’s immediate emotional distress and perceived danger.
D. Asking for details about the stalker may be part of assessment, but it should occur after the client feels safe. Gathering information is secondary to ensuring the client’s immediate safety and emotional stabilization.
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