A nurse is assessing a client with cirrhosis who has become increasingly confused and irritable.

The nurse notes tremors in the client's hands when arms are extended.

The provider suspects hepatic encephalopathy.

Highlight the portions of the passage that reflect signs, causes, and treatments of hepatic encephalopathy.

Some sentences or phrases may be unrelated or incorrect.

The client with cirrhosis appears disoriented and has difficulty answering simple asks.

The nurse observes asterixis when the client extends their arms.

Laboratory results show elevated mental status.

The provider prescribes lactulose to lower ammonia levels.

The client is placed on a high protein diet to support liver regeneration.

The nurse encourages the client to ambulate in the hallway to reduce the risk of acquiring pneumonia.

A CT scan of the brain is ordered to rule out a stroke.

The nurse monitors the client closely for worsening neurologic functions.

Choice A rationale

Allowing a client at risk for suicide to nap with the door closed poses a significant safety concern. This practice eliminates direct visual observation, which is paramount in suicide prevention. The closed door creates an opportunity for the client to engage in self-harm behaviors unobserved, increasing the risk of a successful suicide attempt by removing immediate intervention capabilities.

Choice B rationale

While distraction can be therapeutic, allowing a client on suicide precautions to engage in crafts in their room unobserved introduces potential risks. Craft materials, if not carefully monitored and selected, could be used as instruments for self-harm. Maintaining constant, direct observation, even during seemingly benign activities, is crucial to prevent access to means for suicide.

Choice C rationale

Providing headphones for relaxing music, while potentially calming, can compromise auditory monitoring of a client on suicide precautions. The headphones can obscure sounds that might indicate distress, agitation, or self-harm attempts. Direct sensory observation, including listening for abnormal sounds, is a critical component of ensuring continuous safety and prompt intervention.

Choice D rationale

Rounding and visualizing the client every 15 minutes is a fundamental suicide precaution intervention. This frequent, direct observation allows for continuous assessment of the client's behavior, mood, and immediate environment. It minimizes opportunities for self-harm by providing consistent monitoring and enables timely intervention if any concerning signs or actions are detected, ensuring client safety.

Choice A rationale

Fluid-filled vesicles on the chest are not characteristic of Koplik spots. Vesicular rashes are more commonly associated with conditions like varicella (chickenpox) or herpes zoster, where the viral replication leads to the formation of small, elevated, fluid-filled lesions on the skin surface.

Choice B rationale

Koplik spots are pathognomonic for measles, appearing as small, irregular, bright red spots with bluish-white centers on the buccal mucosa, typically opposite the molars. They represent necrotic epithelial cells in the buccal mucosa and are an early diagnostic sign, often appearing 2-3 days before the generalized rash.

Choice C rationale

Enlarged parotid glands are characteristic of mumps, a viral infection affecting the salivary glands, particularly the parotid glands. This condition leads to swelling and tenderness in the areas anterior to the ears and below the jawline, distinct from the oral lesions seen in measles.

Choice D rationale

A gray pseudomembrane covering the pharynx is a hallmark sign of diphtheria, a bacterial infection caused by *Corynebacterium diphtheriae*. This pseudomembrane is a tough, adherent lesion composed of fibrin, bacteria, and necrotic cells that can obstruct the airway, unrelated to measles.