The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement?

"My condition is a degenerative brain disorder caused by nutrient deficiency."

"There is swelling of my brain that is caused by alcohol consumption."

"The inability of my liver to metabolize the alcohol caused this condition."

"Toxins from the alcohol I drank have caused my brain to swell."

Answer and Explanation

The Correct Answer is A

A. "My condition is a degenerative brain disorder caused by nutrient deficiency." Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency, which is often due to chronic alcoholism. The condition is associated with neurological damage from this nutrient deficiency, making this statement accurate.

B. "There is swelling of my brain that is caused by alcohol consumption." Wernicke encephalopathy is not characterized by brain swelling but by neurological damage due to thiamine deficiency.

C. "The inability of my liver to metabolize the alcohol caused this condition." While liver dysfunction can be associated with alcohol use, Wernicke encephalopathy is specifically due to thiamine deficiency, not liver metabolism issues.

D. "Toxins from the alcohol I drank have caused my brain to swell." This statement is incorrect as Wernicke encephalopathy is related to thiamine deficiency rather than brain swelling from alcohol toxins.

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Correct Answer is B

Explanation

A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.

B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.

C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.

D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.

A. Administer a saline enema for constipation. B. Initiate contact precautions. C. Encourage independence in the completion of ADLs. D. Monitor oral mucosa daily.

Correct Answer is D

Explanation

A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.

B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.

C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.

D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.

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The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement?

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Correct Answer is D

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