A nurse is caring for a client who has Wernicke-Korsakoff psychosis as a result of chronic alcohol use disorder. Which of the following interventions should the nurse anticipate?

Answer:C, D, E

Rationale:

A) Rotate staff that administer the medications: Rotating staff can lead to inconsistency in communication and rapport with the client. A consistent nursing team is more likely to build trust and encourage adherence to medication therapy. Therefore, this intervention may not effectively promote adherence.

B) Engage the client in conversation following medication administration: While engaging the client in conversation can help build rapport and create a supportive environment, it may not be the most effective intervention for encouraging medication adherence. The priority should be focused on ensuring the client takes the medication as prescribed, rather than focusing on conversation after administration.

C) Use sustained-release forms: Sustained-release formulations can help with adherence by providing a more consistent therapeutic effect and reducing the number of doses a client needs to take throughout the day. This can simplify the medication regimen, making it easier for the client to adhere.

D) Provide for once-daily dosing: Once-daily dosing is beneficial for improving adherence because it reduces the complexity of the medication regimen. Clients are more likely to remember to take their medication if they only need to do so once a day.

E) Perform mouth checks following the administration of the medication: Performing mouth checks can help ensure that the client has actually taken the medication, especially if there is suspicion of non-adherence. This intervention can confirm that the medication is ingested and can serve as a prompt for adherence in future doses.

D. Wernicke-Korsakoff psychosis is a neurological disorder caused by thiamine (vitamin B1) deficiency, often resulting from chronic alcohol use disorder. Thiamine deficiency can lead to significant neurological impairments, including confusion, ataxia, and memory deficits characteristic of Wernicke's encephalopathy and Korsakoff's psychosis.

The primary intervention for Wernicke-Korsakoff psychosis is the administration of thiamine supplementation. Thiamine replacement therapy is essential to prevent further neurological deterioration and to potentially reverse some of the cognitive deficits associated with the disorder.

The other options are not directly related to Wernicke-Korsakoff psychosis:

A. Monitoring for the presence of esophageal varices is more relevant to complications of chronic liver disease, such as cirrhosis, commonly seen in individuals with alcohol use disorder, but not specific to Wernicke-Korsakoff psychosis.

B. Placing the client in protective isolation is not indicated for Wernicke-Korsakoff psychosis. Protective isolation is typically used for clients with compromised immune systems to reduce the risk of infection.

C. Laboratory analysis of cardiac enzymes is typically performed to assess for myocardial injury or infarction, which is not directly associated with Wernicke-Korsakoff psychosis.