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 B
Explanation
Choice A reason: A heart murmur is not a common finding in right-sided heart failure unless there is an associated valvular heart disease.
Choice B reason: Dependent edema is a classic sign of right-sided heart failure due to the accumulation of fluid in the tissues, particularly in the lower extremities.
Choice C reason: Chest pain is more commonly associated with left-sided heart failure or other cardiac conditions such as angina.
Choice D reason: Crackles in the lungs are typically found in left-sided heart failure due to pulmonary congestion, not right-sided heart failure.
Correct Answer is ["125"]
Explanation
- Step 1: Identify the required dose in micrograms (mcg). The client is scheduled to receive 125 mcg of digoxin.
- Step 2: Identify the concentration of the available tablet. The available tablet contains 0.25 mg of digoxin.
- Step 3: Convert the tablet concentration from mg to mcg. We know that 1 mg = 1000 mcg. So, 0.25 mg = 0.25 × 1000 mcg = 250 mcg.
- Step 4: Calculate the number of tablets needed to deliver the required dose. We can set up a proportion to solve for this:
- 250 mcg is to 1 tablet as 125 mcg is to X tablets.
- In other words, 250 mcg : 1 tablet = 125 mcg : X tablets.
- Step 5: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 250 mcg × X tablets = 125 mcg × 1 tablet.
- Simplifying this gives us: 250X = 125.
- Dividing both sides by 250 gives us: X = 125 ÷ 250.
- Calculating the division gives us: X = 0.5.
So, the nurse should administer 0.5 tablets per dose to deliver the required dose of 125 mcg.
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