A nurse is caring for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse implement to reduce the client’s ammonia levels?

Restrict the client’s intake of fluids

Administer furosemide as prescribed

Administer vitamin K as prescribed

Limit the client’s intake of protein

Answer and Explanation

The Correct Answer is D

Choice A reason: Restricting fluid intake does not reduce ammonia levels in hepatic encephalopathy. Fluid management addresses ascites or edema, but ammonia accumulates due to impaired liver metabolism of protein, making fluid restriction irrelevant to the goal of lowering ammonia in cirrhosis.

Choice B reason: Administering furosemide treats ascites or edema in cirrhosis by promoting diuresis but does not directly reduce ammonia levels. Ammonia results from protein metabolism, requiring dietary restriction, not fluid loss, making this an ineffective intervention for encephalopathy.

Choice C reason: Administering vitamin K corrects coagulopathy in cirrhosis by aiding clotting factor synthesis but has no effect on ammonia levels. Ammonia accumulates from protein breakdown, requiring protein restriction, making vitamin K irrelevant to managing encephalopathy’s neurological symptoms.

Choice D reason: Limiting protein intake (20-40 g/day) reduces ammonia in hepatic encephalopathy, as the damaged liver cannot metabolize protein, leading to ammonia accumulation. This intervention minimizes ammonia production, alleviating neurological symptoms like confusion, making it the most effective strategy for this condition.

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Correct Answer is B

Explanation

Choice A reason: Nausea is a common post-EGD symptom but not the priority. It is less critical than airway safety, as EGD involves throat anesthesia, risking aspiration if the gag reflex is impaired, making this choice secondary.

Choice B reason: Assessing the gag reflex is the priority post-EGD, as throat anesthesia can impair swallowing, risking aspiration. Ensuring the reflex returns before oral intake prevents airway compromise, making this the most critical assessment.

Choice C reason: Level of consciousness is important, especially post-sedation, but airway protection via gag reflex is more urgent. An intact gag reflex ensures safe swallowing, preventing aspiration, making this choice less immediate.

Choice D reason: Pain is a concern post-EGD but not the priority. Airway safety, ensured by an intact gag reflex, is critical to prevent aspiration, a life-threatening complication, making pain assessment secondary to this choice.

A. Administer antidiuretic hormone desmopressin (DDAVP) B. Maintain an IV infusion of 5% dextrose water C. Initiate fluid restriction of 1,000 mL per day D. Provide a low sodium diet for all meals

Correct Answer is C

Explanation

Choice A reason: Administering desmopressin (DDAVP), a synthetic antidiuretic hormone, is contraindicated in SIADH, as it exacerbates water retention, worsening hyponatremia. Desmopressin is used for diabetes insipidus, where ADH is deficient, not SIADH, where ADH excess causes fluid overload and sodium dilution.

Choice B reason: Maintaining an IV infusion of 5% dextrose water is inappropriate for SIADH, as it adds free water, further diluting serum sodium and worsening hyponatremia (125 mEq/L). Hypertonic saline or fluid restriction is needed to correct sodium imbalance, making this intervention incorrect.

Choice C reason: Initiating fluid restriction (e.g., 1,000 mL/day) is appropriate for SIADH, as it reduces water intake, allowing the kidneys to excrete excess water, raising serum sodium levels. This corrects hyponatremia (125 mEq/L) caused by ADH-driven water retention, making it the primary intervention.

Choice D reason: Providing a low sodium diet is not indicated for SIADH, as the primary issue is water retention, not sodium intake. Restricting sodium could worsen hyponatremia by further reducing serum sodium availability, making fluid restriction a more effective intervention for this condition.

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A nurse is caring for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse implement to reduce the client’s ammonia levels?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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