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

• A. Confusion
• B. Euphoria
• C. Severe headache
• D. Seizures

Answer: (A)

Confusion signals acute brain dysfunction from thiamine deficiency, which is the central issue in Wernicke's encephalopathy. When planning care, the presence of confusion shapes priorities: ensuring safety (preventing falls and aspiration), performing regular neuro checks to track changes, and providing urgent thiamine replacement along with nutritional support. While other signs like eye movement abnormalities or ataxia may occur, altered mental status is the most actionable indicator for guiding the care plan. Euphoria, severe headache, and seizures aren’t the defining features that drive immediate nursing actions in this condition.