A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
Asterixis
Change in orientation
Anorexia
Ascites
Fetor hepaticus
Correct Answer : A,B,E
Choice A reason: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, often seen in hepatic encephalopathy as a result of altered brain function.
Choice B reason: A change in orientation, including confusion and altered consciousness, is a hallmark of hepatic encephalopathy, reflecting the brain's impaired ability to process information.
Choice C reason: Anorexia may be present in cirrhosis, but it is not a specific indicator of hepatic encephalopathy.
Choice D reason: Ascites is a common complication of cirrhosis due to portal hypertension but is not a direct indicator of hepatic encephalopathy.
Choice E reason: Fetor hepaticus, a musty odor of the breath, is a distinctive symptom of hepatic encephalopathy caused by the presence of mercaptans in the breath as the liver fails to break down sulfur-containing amino acids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:Shaking the bag is not recommended as it may not adequately mix the solution and could cause emulsion instability.
Choice B reason:Administering the bag as is could be harmful due to the risk of fat embolism or other complications from an unstable emulsion.
Choice C reason:Returning the bag to the pharmacy is the appropriate action to ensure the client receives a properly mixed and safe emulsion.
Choice D reason:Turning the bag upside down one time is not sufficient to mix the emulsion and does not address the potential instability of the solution.
Correct Answer is A
Explanation
Choice A reason: Administering oxygen therapy is the first and immediate intervention for a client with a pulmonary embolism to address hypoxemia.
Choice B reason: Starting an IV infusion of Lactated Ringer's is important for fluid resuscitation but is not the first intervention for pulmonary embolism.
Choice C reason: Initiating cardiac monitoring is important for observing the client's heart function but comes after ensuring the client is receiving adequate oxygen.
Choice D reason: Giving morphine IV may be used for pain management in pulmonary embolism but is not the first-line intervention.
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