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 A

Explanation

A. drowsiness: Drowsiness is a common side effect of many antianxiety medications, especially benzodiazepines. This can impair the client’s ability to safely drive or perform tasks requiring alertness, making this the most appropriate choice.

B. confusion: While confusion can occur with some antianxiety drugs, it is less common than drowsiness and typically occurs at higher doses or with prolonged use.

C. behavior changes: Behavior changes can occur but are less common and are not the primary reason for caution with activities requiring mental alertness.

D. sleep disorders: Sleep disorders are not a typical side effect of antianxiety medications; in fact, these drugs are often used to treat sleep disturbances.

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. C. Advising the client to report weight gain and skin rashes to the health care provider immediately. D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. E. Administering the medication subcutaneously when the client is unable to swallow effectively.

Correct Answer is ["A","B","C","D"]

Explanation

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.

B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.

C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.

D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.

E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.

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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?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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