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 ["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.
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.
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