A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

Thiamine deficiency

Hypothalamic and mammillary body lesions

Inability to learn new skills and short-term memory loss

Double vision and rapid eye movement

Answer and Explanation

The Correct Answer is B

A.   Wernicke encephalopathy is caused by thiamine (Vitamin B1) deficiency, but it is not characterized by thiamine deficiency itself.
B.   Wernicke encephalopathy is characterized by lesions in the hypothalamus and mammillary bodies in the brain.
C.   While cognitive impairment may be present, this is not the primary characteristic of Wernicke encephalopathy.
D.   Double vision and rapid eye movement are symptoms of Wernicke encephalopathy, but they are not the irreversible complication itself.

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Correct Answer is B

Explanation

A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.

B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.

C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.

A. Placing the client on one-on-one observation while monitoring for suicidal ideations B. Conducting 15minute checks to ensure safety C. Encouraging the client to verbalize feelings related to suicide D. Completing a room search to ensure there are no harmful objects available to the client.

Correct Answer is A

Explanation

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

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A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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