A client with end-stage liver failure becomes increasingly confused and lethargic.
The nurse notes asterixis. Which intervention should the nurse anticipate?

Administer vitamin K.

Decrease protein intake.

Administer lactulose.

Restrict sodium intake.

Answer and Explanation

The Correct Answer is C

The clinical presentation of asterixis and lethargy in liver failure indicates hepatic encephalopathy. Knowledge of nitrogenous waste metabolism and the pharmacological action of osmotic laxatives is necessary to address the buildup of neurotoxic ammonia levels within the systemic circulation.

Choice A rationale

Vitamin K is essential for synthesizing clotting factors II, VII, IX, and X in the liver. While liver failure causes coagulopathy, this intervention does not address the neurological symptoms caused by elevated ammonia or metabolic encephalopathy.

Choice B rationale

Historically, protein restriction was used to limit ammonia production. However, modern guidelines emphasize maintaining adequate protein intake to prevent muscle wasting and malnutrition, which can actually worsen the clinical outcomes and metabolic status in cirrhotic patients.

Choice C rationale

Lactulose is a synthetic disaccharide that acidifies colonic contents. This converts ammonia into ammonium, which is poorly absorbed and excreted via stool. It is the gold standard for reducing neurotoxic ammonia levels in hepatic encephalopathy.

Choice D rationale

Sodium restriction is primarily utilized to manage fluid retention and ascites in portal hypertension. While important for volume control, it does not directly impact the cerebral edema or neurotoxicity associated with the presence of asterixis.

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Correct Answer is A

Explanation

Managing diabetic ketoacidosis involves addressing hyperglycemia, ketosis, and metabolic acidosis. Applying knowledge of insulin pharmacokinetics is essential, specifically identifying which insulin preparation is suitable for intravenous administration to rapidly reduce blood glucose and halt ketone production in emergencies.

Choice A rationale

Regular insulin is a short-acting preparation and the only insulin that can be administered intravenously. It rapidly lowers blood glucose and reverses ketoacidosis by inhibiting lipolysis. Onset is 30 to 60 minutes when given subcutaneously.

Choice B rationale

Insulin detemir is a long-acting basal insulin analog with a slow, steady release profile over 24 hours. It lacks a peak and cannot be given intravenously, making it inappropriate for the acute management of diabetic ketoacidosis.

Choice C rationale

NPH insulin is an intermediate-acting insulin containing protamine to delay absorption. It has an onset of 1 to 2 hours and is used for maintenance, not for the rapid correction of life-threatening metabolic acidosis.

Choice D rationale

Insulin glargine is a long-acting basal insulin that provides a constant concentration for 24 hours. It is used for long-term glycemic control and cannot be administered intravenously for emergent stabilization of diabetic ketoacidosis.

A. Provide frequent oral and nares care. B. Encourage the client to consume clear liquids. C. Ambulate the client four times per day. D. Keep the client in a supine position.

Correct Answer is A

Explanation

Managing esophagogastric balloon tamponade requires knowledge of airway protection and mucosal integrity. Applying nursing interventions for a client with a Sengstaken-Blakemore tube involves preventing complications like aspiration and tissue necrosis while maintaining the mechanical pressure needed for hemostasis.

Choice A rationale

Frequent oral and nares care is essential because the tube causes irritation and prevents the client from swallowing saliva. Secretions accumulate in the upper airway, increasing infection risk and skin breakdown at the insertion site.

Choice B rationale

Clients with a Sengstaken-Blakemore tube must remain strictly NPO to prevent aspiration and avoid disturbing the tube. The balloon occupies the esophagus and stomach to stop variceal bleeding, making oral intake impossible and extremely dangerous.

Choice C rationale

Ambulation is contraindicated for a client with an active balloon tamponade due to the risk of tube displacement. Displacement can lead to airway obstruction if the gastric balloon migrates upward into the oropharynx or trachea.

Choice D rationale

A supine position increases the risk of aspiration and respiratory distress. The nurse should maintain the head of the bed at 30 to 45 degrees to facilitate breathing and minimize the risk of pulmonary complications.

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A client with end-stage liver failure becomes increasingly confused and lethargic. The nurse notes asterixis. Which intervention should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A client with end-stage liver failure becomes increasingly confused and lethargic.
The nurse notes asterixis. Which intervention should the nurse anticipate?