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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A: Troponin Troponin levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. Troponin is a protein found in cardiac muscle fibers that regulates muscular contraction. When heart muscle is damaged, as in the case of an MI, troponin is released into the bloodstream. The elevation of troponin levels is a key indicator of myocardial infarction and can be used to diagnose and assess the extent of heart muscle damage. Troponin is the most reliable laboratory value that is expected to be elevated following a myocardial infarction, making it the correct choice in this scenario.

Choice B: Aspartate aminotransferase (AST) AST is an enzyme found in high concentrations in the liver, heart, muscles, kidneys, and brain. It is released into the bloodstream when any of these tissues are damaged. While AST can be elevated in cases of MI, it is not as specific as troponin because it is present in many other tissues besides the heart.

Choice C: Serum amylase Serum amylase is an enzyme that helps digest carbohydrates and is primarily associated with the pancreas and salivary glands. Its elevation is not specifically related to myocardial infarction but can be seen in other conditions such as pancreatitis.

Choice D: Unconjugated bilirubin Unconjugated bilirubin is a breakdown product of hemoglobin from red blood cells. Elevated levels of unconjugated bilirubin are typically associated with conditions affecting the liver or the breakdown of red blood cells, not myocardial infarction.

A. Atropine B. Furosemide C. Heparin D. Dexamethasone

Correct Answer is C

Explanation

Choice A reason: Atropine is not typically used for the treatment of pulmonary embolism. It is an anticholinergic drug that is primarily used to treat bradycardia (slow heart rate) and as part of the management of organophosphate poisoning. It does not have a role in the management of pulmonary embolism, which requires anticoagulation to prevent further clot formation.

Choice B reason: Furosemide is a loop diuretic commonly used to treat fluid overload conditions such as heart failure or edema. While it can help relieve symptoms associated with fluid accumulation, it does not treat the underlying cause of a pulmonary embolism, which is a blood clot in the pulmonary arteries.

Choice C reason: Heparin is an anticoagulant medication that is commonly used in the initial treatment of pulmonary embolism. It works by preventing the formation of new blood clots and stopping existing clots from getting bigger. Heparin is often administered intravenously or subcutaneously and is a key component in the management of pulmonary embolism.

Choice D reason: Dexamethasone is a corticosteroid that is used to reduce inflammation in various conditions, such as allergic reactions, asthma, and certain types of arthritis. It is not used as a primary treatment for pulmonary embolism, as it does not have anticoagulant properties.

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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).

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