A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

Administering iron supplements as prescribed.

Monitoring fluid intake and output.

Implementing seizure precautions.

Encouraging high-protein diet intake.

Answer and Explanation

The Correct Answer is C

A) Iron supplements are not a priority intervention for a client with hepatic encephalopathy. In fact, administering iron supplements without proper indication can be harmful, as excessive iron can worsen liver damage in cirrhosis.

B) While monitoring fluid intake and output is important in managing various aspects of liver cirrhosis, it is not the essential intervention for hepatic encephalopathy. The priority in hepatic encephalopathy is to ensure seizure precautions and address the client's altered mental status.

C) Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis that can lead to altered mental status, confusion, and potential seizures. Implementing seizure precautions is essential in the care of this client to ensure their safety and prevent injury during any potential seizure activity. Seizure precautions may include padding the side rails of the bed, ensuring a clear and clutter-free environment, and providing close supervision to the client. In severe cases, the healthcare provider may prescribe antiepileptic medications to manage and prevent seizures.

D) Encouraging a high-protein diet is not appropriate for a client with hepatic encephalopathy. High-protein diets can exacerbate hepatic encephalopathy by increasing ammonia production in the intestines. Instead, the client should be prescribed a controlled-protein diet and, in some cases, given lactulose to help reduce ammonia levels.

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Correct Answer is D

Explanation

A) Serum albumin is a protein synthesized by the liver, and its levels are often decreased in advanced liver cirrhosis due to impaired liver function. However, the question asks for an elevated finding, not a decreased one.

B) Prothrombin time (PT) measures the time it takes for blood to clot. In liver cirrhosis, PT is often prolonged due to impaired liver function and reduced production of clotting factors. However, the question asks for an elevated finding, not a prolonged one.

C) Aspartate aminotransferase (AST) is an enzyme found in the liver and other organs. While AST levels may be elevated in liver cirrhosis, it is not a specific marker for liver cirrhosis, and its elevation can occur in various liver diseases and conditions.

D) In liver cirrhosis, impaired liver function leads to reduced clearance of bilirubin, resulting in elevated total bilirubin levels in the blood. Elevated bilirubin is a common finding in liver cirrhosis and can contribute to jaundice.

A. Encouraging the client to increase protein intake. B. Assisting the client with frequent ambulation. C. Administering diuretics as prescribed by the healthcare provider. D. Teaching the client deep breathing exercises.

Correct Answer is C

Explanation

A) While adequate protein intake is important for overall health, encouraging the client to increase protein intake is not a priority in managing ascites. The priority is to address fluid retention through diuretic therapy.

B) While ambulation can be beneficial for clients with liver cirrhosis, it is not the priority for managing ascites. Diuretic therapy is more directly targeted at reducing fluid accumulation.

C) The priority nursing intervention for managing ascites in a client with liver cirrhosis is administering diuretics as prescribed by the healthcare provider. Diuretics help reduce fluid retention and alleviate the pressure caused by the accumulation of fluid in the abdomen. This intervention aims to improve the client's comfort and prevent the development of further complications associated with ascites.

D) Deep breathing exercises can be helpful for clients with liver cirrhosis, but they are not the priority for managing ascites. The focus should be on diuretic therapy and addressing the fluid retention in the abdomen.

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A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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