Ok, here's another NCLEX-type question for you

[Nuieve]

The nurse is caring for a client who is experiencing marked confusion, unsteady gait and diplopia after being admitted to the hospital for alcohol withdrawal. Which of the following nursing interventions is the priority for the nurse to implement?

1. Encourage adequate nutrition and fluids.

2. Administer prescribed thiamine.

3. Provide safety measures.

4. Administer prescribed benzodiazepine.

Please don't consult any books, and answer it right away as you would do on the actual exam. I'm curious if it's a hard question or if I have poor critical thinking skills (well, they are poor, but I want to know how poor). :)

[Sunshine97]

I can see why you all thought three is the answer. My initial choice might

be that one too. The important thing is that the symptoms prescribed

sound like Wernicke's encephalopathy and the primary treatment is high

doses of Thiamine, which will reverse eye signs within 2-3 hours of

treatment. While safety is important, you want to stop Wernicke's

syndrome before it progresses into irreversible Korsakoff's syndrome. On

the NCLEX, you would have to know that the symptoms described were

Wernick's syndrome, and then your answer would be prioritized using

Maslow's hierarchy, which starts with physiological needs, then safety.

[morte, LPN, LVN]

hmm so the patient can fall over and kill them selves, whilst i run and get the B1? and i thought safety was a physiologic need....beside the fact that the patient should have a banana bag infusing on admission......

last research i read says that benfotamine works better in ETOH abusers

[Nuieve]

Maybe in NCLEX reality the drugs immediately materialize in the air right next to nurses when they need them so they don't have to run anywhere :)

[gt4everpn, BSN, RN]

The answer is 3, ABC's and safety, no ABC for this pt so safety's first.

[Mytonezucs]

If the med is prescribed you would give it providing it's the right drug etc. When would you not provide safety for the client? This is the pointless hair splitting that fails people for nothing.

I was stuck on both answers because in the real world both answers would apply. You wouldn't stand there wondering if you're going to give the drug or raise the siderails.

If they wanted to know if you knew the proper med why not just make that the question?

[pagandeva2000, LPN]

If the med is prescribed you would give it providing it's the right drug etc. When would you not provide safety for the client? This is the pointless hair splitting that fails people for nothing.

I was stuck on both answers because in the real world both answers would apply. You wouldn't stand there wondering if you're going to give the drug or raise the siderails.

If they wanted to know if you knew the proper med why not just make that the question?

That is what I believe, also. I think that is a crazy rationale (not you, original poster...the book that issued this insane question). The first thing I would have done is raise the freaking siderails before I went chasing to the pharmacy to get the thiamine. As you mentioned, this pointless hair splitting is as useless as a fly on food. If this was the question to make or break a person, then, I'd break the computer in two. Makes me think it is in fact, lucky guesses or confusion to pass that insane exam.

[pagandeva2000, LPN]

Maybe in NCLEX reality the drugs immediately materialize in the air right next to nurses when they need them so they don't have to run anywhere :)

Yeppers...it means regurgitating what NCLEX wants to hear...whether it makes sense or not. That NCLEX reality would probably get me fired from the real world job that I have...

[Sunshine97]

hmm so the patient can fall over and kill them selves, whilst i run and get the B1? and i thought safety was a physiologic need....beside the fact that the patient should have a banana bag infusing on admission......

last research i read says that benfotamine works better in ETOH abusers

If you work in a team your pt will not fall over cause someone else will get the drug for you

[morte, LPN, LVN]

If you work in a team your pt will not fall over cause someone else will get the drug for you

but i dont believe that was an option......

[Sunshine97]

but i dont believe that was an option......

Note my rationale and see why irreversible you thinking safety look at it from a maslow point of view it will make sense.

[suzanne4, RN]

let this serve as a warning:

it is in violation of us copyright law to post any questions like this on any forum, they were written and they are owned by that book/cd.

and that book had an incorrect answer. the correct one would be safety. not the meds or anything else. if the patient falls trying to get out of their bed, then all is lost on top of the rest.

[suzanne4, RN]

Please refer to the sticky at the top of this forum concerning posting of questions and their choice of answers.

You can easily discuss what was included in a question that you are having issues with, but to do it this way actually violated US copyright laws. And we do not want any legal repurcussions here.

Thanks in advance for your understanding.

Thread is closed.