A client with end-stage cirrhosis and hepatic encephalopathy becomes increasingly confused and drowsy.
Which intervention should the nurse implement to reduce ammonia levels?

Administer loop diuretics.

Administer lactulose as prescribed.

Restrict fluid intake.

Increase the client's intake of protein.

Answer and Explanation

The Correct Answer is B

Managing hepatic encephalopathy requires understanding the biochemical role of ammonia in brain toxicity. Knowledge of the enterohepatic circulation and the pharmacological action of osmotic laxatives is necessary to facilitate the excretion of nitrogenous wastes and improve neurological status.

Choice A rationale

Loop diuretics are used to treat ascites or edema but do not directly lower serum ammonia. Excessive diuresis can actually trigger hepatic encephalopathy by causing dehydration and electrolyte imbalances, such as hypokalemia, which increases renal ammonia production and toxicity.

Choice B rationale

Lactulose is a disaccharide that acidifies the colon, converting ammonia into non-absorbable ammonium ions. This osmotic effect also promotes bowel movements, facilitating the rapid excretion of these toxins from the gut, thereby reducing blood ammonia levels and confusion.

Choice C rationale

Restricting fluids does not lower ammonia and can worsen hepatic encephalopathy by causing dehydration and constipation. Adequate hydration and bowel motility are necessary to ensure that nitrogenous wastes are flushed from the gastrointestinal tract effectively to prevent systemic accumulation.

Choice D rationale

Protein breakdown in the gut by bacteria produces ammonia. Increasing protein intake in a client with end stage cirrhosis would likely worsen encephalopathy by providing more nitrogenous substrate for ammonia synthesis, further elevating toxic levels in the blood.

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Correct Answer is C

Explanation

Managing an open pneumothorax requires immediate stabilization of the chest wall to restore pleural pressure dynamics. Knowledge of respiratory mechanics and the prevention of tension pneumothorax is essential to prioritize the correct occlusive dressing technique before proceeding with secondary medical interventions.

Choice A rationale: While a chest tube is the definitive treatment to re-expand the lung and drain the pleural space, it is not the first action. The immediate life-threatening air leak through the wound must be addressed first to stabilize the patient.

Choice B rationale: Administering high-flow oxygen is supportive and necessary, but it will not resolve the primary issue of an open sucking chest wound. Without sealing the atmospheric air entry point, the patient's respiratory effort will remain severely compromised by the pneumothorax.

Choice C rationale: Applying a sterile occlusive dressing taped on three sides creates a one-way valve. This allows trapped air to escape the pleural space during expiration while preventing atmospheric air from entering during inspiration, effectively preventing the development of a tension pneumothorax.

Choice D rationale: Initiating large-bore IV access is a critical part of trauma resuscitation to manage potential shock and administer fluids. However, in the hierarchy of trauma care, the "Breathing" intervention of sealing a sucking chest wound takes precedence over "Circulation" access.

A. The unlicensed assistive personnel tied the confused client to a chair with a sheet. B. The unlicensed assistive personnel escorted the client downstairs to smoke a cigarette. C. The unlicensed assistive personnel assisted the client in ambulating to the dayroom area. D. The unlicensed assistive personnel bought the client a carbonated beverage from the cafeteria.

Correct Answer is A

Explanation

This scenario requires applying knowledge of safety protocols, legal standards for restraint use, and nursing delegation. Understanding that using sheets as makeshift restraints is illegal and dangerous is critical for maintaining patient safety and adhering to healthcare regulations regarding physical interventions.

Choice A rationale

Using sheets as restraints is a violation of safety standards and patient rights. Restraints require a specific medical order and must be manufactured devices. Improper tying can cause skin breakdown, strangulation, or impaired circulation in confused patients.

Choice B rationale

While smoking is generally discouraged in healthcare facilities, escorting a stable patient outdoors does not constitute an immediate safety emergency compared to illegal restraint. It requires a policy review rather than an emergency clinical intervention by the supervisor.

Choice C rationale

Assisting with ambulation is a standard task for unlicensed personnel. In a rehabilitation unit, promoting mobility is a key goal. This action is appropriate unless the patient is specifically designated as bedrest or requires a therapist.

Choice D rationale

Providing a beverage is generally within the scope of unlicensed staff unless the patient is NPO or on a restricted diet. While carbonation may not be ideal, it does not pose an immediate physical threat.

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A client with end-stage cirrhosis and hepatic encephalopathy becomes increasingly confused and drowsy.
Which intervention should the nurse implement to reduce ammonia levels?