A client has been administered lactulose for several days.
Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?
Improved mental status.
Increase in urine output.
Reduction in number of liquid stools.
Ability to ambulate independently.
The Correct Answer is A
Choice A rationale:
Lactulose directly addresses the primary cause of hepatic encephalopathy, which is the accumulation of ammonia in the blood. Ammonia is a neurotoxin that can impair brain function, leading to confusion, lethargy, and even coma. Lactulose works by trapping ammonia in the colon, where it can be safely excreted in the stool. This decrease in ammonia levels in the blood allows for the improvement of mental status.
Studies have consistently shown that lactulose therapy can significantly improve mental function in patients with hepatic encephalopathy. This improvement is often seen within a few days of starting treatment.
The nurse should assess the client's mental status regularly to monitor for improvement. This assessment should include evaluating the client's level of consciousness, orientation, attention, memory, and speech.
Improved mental status is a critical therapeutic goal in the treatment of hepatic encephalopathy. It allows patients to regain their independence and participate more fully in their care.
Choice B rationale:
While lactulose can cause diarrhea, which may lead to a slight increase in urine output, this is not the primary therapeutic response that the nurse should expect.
The increase in urine output is typically secondary to the diarrhea and does not directly reflect a reduction in ammonia levels or improvement in mental status.
Choice C rationale:
Lactulose does cause diarrhea, which is a common side effect of the medication.
However, the goal of lactulose therapy is not to reduce the number of liquid stools but rather to trap ammonia in the colon and promote its excretion.
The nurse should monitor the client's stool frequency and consistency to ensure that they are not experiencing excessive diarrhea, which could lead to dehydration and electrolyte imbalances.
Choice D rationale:
While improved mental status may eventually lead to improved mobility, it is not the most immediate or direct therapeutic response that the nurse should expect from lactulose therapy.
The ability to ambulate independently is more likely to be a long-term goal of treatment, rather than an immediate response to lactulose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While some individuals with Crohn's disease may find that avoiding gluten improves their symptoms, this is not a universal recommendation.
Gluten restriction is more often indicated for those with celiac disease or gluten sensitivity.
It's important to individualize dietary recommendations based on personal triggers and sensitivities.
Choice B rationale:
An elimination diet is a systematic approach to identifying foods that may trigger or worsen Crohn's disease symptoms.
It involves removing certain foods from the diet for a period of time, typically 2-4 weeks, and then gradually reintroducing them one at a time to observe any reactions.
This process can help individuals pinpoint specific foods that contribute to their symptoms and make informed dietary choices to manage their condition.
Choice C rationale:
There is no evidence to support a general restriction of calcium and iron in individuals with Crohn's disease.
In fact, these nutrients are essential for overall health and should be consumed in adequate amounts unless a specific deficiency or intolerance is identified.
Restriction of these nutrients could lead to nutritional deficiencies.
Choice D rationale:
Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease.
Maintaining adequate hydration is crucial for overall health, especially during flares when fluid loss through diarrhea may be increased.
Restricting fluids could potentially lead to dehydration and electrolyte imbalances.
Correct Answer is A
Explanation
Choice A rationale:
Liquefying secretions is the most crucial action to address the client's immediate respiratory concerns. Thickened mucus obstructs airflow, leading to shortness of breath, productive cough, and difficulty breathing upon exertion. Increasing fluid intake thins mucus, making it easier to expel and improving ventilation. This directly addresses the client's current symptoms and promotes airway clearance.
Hydration and Mucociliary Clearance: Adequate hydration is indispensable for optimal mucociliary clearance, the natural mechanism that removes mucus from the airways. Fluids moisten the respiratory tract, allowing cilia (tiny hair-like structures) to effectively move mucus upwards, where it can be coughed out or swallowed.
Thinning Mucus: Water acts as a natural expectorant, thinning mucus and reducing its viscosity. This makes it easier for the client to cough up the mucus, clearing the airways and reducing the sensation of breathlessness.
Decreasing Mucus Production: Dehydration can trigger the body to produce more mucus as a protective response. By staying hydrated, the client can help prevent excessive mucus production, further easing symptoms.
Supporting Overall Respiratory Health: Proper hydration maintains the health of the respiratory system's tissues and cells, promoting efficient gas exchange and reducing inflammation.
Preventing Dehydration-Related Complications: Dehydration can exacerbate respiratory problems and lead to other complications, such as fatigue, headaches, and impaired immune function. Maintaining adequate fluid intake helps prevent these issues.
Key points to emphasize to the client:
Drink fluids throughout the day, even if not feeling thirsty.
Water is the best choice, but clear broths, juices, and herbal teas can also contribute to fluid intake. Avoid caffeine and alcohol, as they can be dehydrating.
Monitor urine output to ensure adequate hydration (urine should be pale yellow or clear).
Increase fluid intake during periods of increased mucus production, such as during respiratory infections or exercise.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.