A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement?

Provide with only finger foods.

Feed the client the entire meal.

Orient the client to the location of the food on the plate.

Ask family to visit during meal time to assist with feeding.

Answer and Explanation

The Correct Answer is C

A. Providing only finger foods unnecessarily limits the client’s diet and independence. The client may be able to eat with utensils if properly guided, so restricting to finger foods is not required.

B. Feeding the client the entire meal removes the client’s autonomy and may not be necessary. Many clients with visual impairments can feed themselves with proper orientation and assistance.

C. Orienting the client to the location of food on the plate is the most appropriate intervention. Using techniques such as the “clock method,” where different foods are described in terms of clock positions, helps the client eat independently and safely despite visual impairment. This approach promotes autonomy and reduces the risk of spills or injury.

D. Asking family to assist during meal times may provide support, but it is not the primary strategy for fostering independence and safety. The UAP should first use structured orientation techniques to help the client feed themselves.

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Correct Answer is D

Explanation

A. Right lower abdominal pain is not associated with Wernicke’s syndrome. This finding would suggest a gastrointestinal issue, such as appendicitis, and is unrelated to the neurological effects of thiamine deficiency.

B. Peripheral neuropathy can occur with chronic thiamine deficiency, but it is more commonly associated with beriberi. While it may be present, it is not the hallmark feature used to guide immediate care planning for Wernicke’s syndrome.

C. Depression may be seen in chronic alcohol use or malnutrition, but it is not a defining or urgent feature of Wernicke’s syndrome. Addressing depression is important but secondary to preventing acute neurological deterioration.

D. Confusion is a key clinical feature of Wernicke’s syndrome and reflects the acute neurocognitive effects of thiamine deficiency. It is part of the classic triad (confusion, ataxia, ophthalmoplegia) and is critical for developing the care plan. Immediate recognition and treatment with thiamine are essential to prevent progression to Wernicke-Korsakoff syndrome, which can cause irreversible cognitive impairment.

A. Endocarditis. B. Stevens-Johnson syndrome. C. Pityriasis rosea. D. Anaphylactic reaction.

Correct Answer is B

Explanation

A. Endocarditis is an infection of the inner lining of the heart and heart valves. It typically presents with fever, heart murmur, fatigue, and sometimes petechiae or splinter hemorrhages, but it does not cause widespread red-purple blistering rashes on the skin and mucous membranes. Therefore, this presentation does not match endocarditis.

B. Stevens-Johnson syndrome (SJS) is a severe, potentially life-threatening hypersensitivity reaction usually triggered by medications such as antibiotics (including azithromycin), anticonvulsants, or NSAIDs. SJS typically begins with flu-like symptoms such as fever, malaise, and body aches, followed by a painful, rapidly progressing rash that involves red or purplish macules, blisters, and erosions affecting both the skin and mucous membranes of the mouth, eyes, nose, and genitals. This presentation closely matches the client’s symptoms. Immediate discontinuation of the offending drug and urgent medical care are required.

C. Pityriasis rosea is a mild, self-limiting skin condition that typically presents as a herald patch followed by a generalized oval-shaped rash on the trunk and proximal limbs. It does not involve mucous membranes or blistering, nor does it usually accompany flu-like symptoms.

D. An anaphylactic reaction is an acute, systemic allergic response that develops rapidly after exposure to an allergen, causing symptoms such as hypotension, bronchospasm, angioedema, hives, and difficulty breathing. While it is serious and requires emergency treatment, it does not typically present with mucous membrane blistering and the described rash pattern.

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A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A client who is currently receiving azithromycin for an infection reports flu-like symptoms for the past couple of days and a new onset of red and purplish rash with blisters on the skin and mucous membranes of the mouth, nose, eyes, and genitals. Which condition presents with these findings?

Correct Answer is B

Explanation

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