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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Agranulocytosis: Carbamazepine carries a boxed warning for serious hematologic effects, including agranulocytosis and aplastic anemia. Agranulocytosis is a significant drop in white blood cell count, leading to a high risk of infection.
B. Birth defects: While carbamazepine is associated with birth defects when taken during pregnancy, the boxed warning specifically highlights the risk of severe blood disorders like agranulocytosis.
C. Skin rash: Carbamazepine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, but the boxed warning focuses more on the hematologic risks.
D. Liver damage: Although carbamazepine can cause liver damage, this is not the primary focus of the boxed warning, which emphasizes hematologic effects.
Correct Answer is B
Explanation
A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.
B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.
C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.
D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.
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