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) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not typically associated with difficulty sleeping or shortness of breath.

B) Portal hypertension, a common complication of liver cirrhosis, can lead to the development of ascites and esophageal varices, among other manifestations. It is not the likely cause of the client's difficulty sleeping and shortness of breath.

C) Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease and is not associated with difficulty sleeping or shortness of breath.

D) Hepatopulmonary syndrome is a complication of liver cirrhosis characterized by the development of pulmonary vascular dilation and arteriovenous shunting. This results in impaired oxygenation of blood, leading to difficulty breathing (dyspnea), especially while lying down (orthopnea). Clients with hepatopulmonary syndrome often experience frequent awakenings due to shortness of breath during sleep.

A. Administer pain medication to alleviate discomfort. B. Document the findings and continue monitoring the client. C. Obtain an order for a liver biopsy to assess liver function. D. Notify the healthcare provider immediately.

Correct Answer is D

Explanation

A) Pain medication is not appropriate for managing altered mental status and confusion. The priority is to identify and address the underlying cause of the client's symptoms.

B) While documentation and ongoing monitoring are important, the priority is to take immediate action when the client is exhibiting signs of altered mental status. The nurse should promptly notify the healthcare provider for further evaluation and intervention.

C) A liver biopsy is a diagnostic procedure that provides information about the degree of liver damage and fibrosis. However, it is not the first action to take when the client is experiencing altered mental status and confusion. Immediate notification of the healthcare provider is the priority in this situation.

D) Altered mental status and confusion in a client with liver cirrhosis can indicate hepatic encephalopathy, a serious complication of advanced liver disease. Hepatic encephalopathy results from the accumulation of toxic substances in the blood due to impaired liver function. The nurse should prioritize notifying the healthcare provider immediately to initiate appropriate interventions and prevent further deterioration of the client's condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?

Correct Answer is D

Explanation

A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?

Correct Answer is D

Explanation

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