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    Hesi Rn compass exit B proctored exam

    A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care?

    Explanation & Rationale

    Rationale: A. Peripheral neuropathy: Although peripheral neuropathy may occur with chronic alcohol use, it is more commonly associated with peripheral nerve damage over time and is not the hallmark of Wernicke's syndrome. B. Right lower abdominal pain: This is not characteristic of Wernicke's syndrome and is more indicative of appendicitis or gastrointestinal conditions. C. Confusion: Wernicke’s syndrome (Wernicke’s encephalopathy) is a neurologic disorder caused by thiamine deficiency, often related to chronic alcoholism. Key symptoms include confusion, ataxia, and ophthalmoplegia, making confusion a central assessment to guide care. D. Depression: While mood disorders can coexist in individuals with alcohol use disorder, depression is not a defining feature of Wernicke’s syndrome and does not guide immediate nursing priorities for this diagnosis.

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