A nurse is caring for a client with Wernicke-Korsakoff syndrome. The nurse observes rapid eyeball movement from side to side. What term should the nurse use to document rapid eyeball movement from side to side in the client?
A) Delirium tremens
B) Palmar erythema
C) Spider angioma
D) Horizontal nystagmus
D
Feedback:
The nurse should document the rapid eyeball movement from side to side observed in the client as horizontal nystagmus. Delirium tremens is the condition wherein the client has vivid and terrifying auditory, visual, and tactile hallucinations; it is an indicator of a severe toxic state during stage 3 of unmanaged alcohol withdrawal. Spider angioma and palmar erythema are signs of chronic alcoholism. Spider angioma is a condition in which the client has spidery veins on the nose and cheeks. Palmar erythema is the condition of thickened and reddened palms.
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