A nurse is caring for a client who is postoperative following a thoracotomy with lung resection 24 hr ago.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

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due to

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postoperatively.

Rationale:
A. Contact the provider who will be performing the procedure: It is the provider’s legal and ethical responsibility to explain the procedure, including its purpose, risks, benefits, and alternatives. If the client does not understand, the nurse must contact the provider to clarify and ensure informed consent is valid.

B. Instruct the client's spouse to sign the consent form: A spouse may only sign the form if the client is legally unable to do so. If the client is competent but lacks understanding, they should not sign until they receive adequate information from the provider.

C. Read the consent form to the client using words the client will understand: While the nurse can clarify terms, reading or paraphrasing the consent form does not replace the provider’s obligation to explain the procedure fully and answer questions.

D. Provide teaching about the surgical procedure for the client: Nurses may reinforce information, but only the provider can give the detailed explanation required for informed consent. Providing full procedural teaching falls outside the nurse’s scope for consent purposes.

Rationale:

• Hepatic encephalopathy: This is caused by the buildup of neurotoxins, particularly ammonia, due to impaired liver function. The client’s elevated ammonia level and history of chronic alcohol use and jaundice support this diagnosis. Early signs may include confusion and lethargy, progressing to coma if untreated.
• Uremic encephalopathy: This condition is caused by accumulation of urea and toxins due to kidney failure. There is no evidence in the case of renal impairment, such as elevated BUN or creatinine levels, making this diagnosis unlikely in the current context.
• Hypoglycemia: Low blood glucose can cause confusion or altered mental status, but this client’s symptoms and labs do not indicate hypoglycemia. There is no mention of a low glucose level, and the focus of concern is more aligned with liver failure than endocrine causes.

• Abdominal pain: Although abdominal pain is a relevant symptom in liver disease, it is nonspecific and not directly responsible for hepatic encephalopathy. It reflects general liver inflammation or ascites but does not cause neurologic symptoms on its own.
• Albumin 3.0 g/dL: Low albumin indicates reduced liver synthetic function and contributes to fluid shifts like ascites, but it is not neurotoxic. It does not directly cause hepatic encephalopathy or altered mental status.
• Ammonia 150 mcg/dL: This is a critically elevated value, more than double the normal upper limit. High ammonia levels are the most direct biochemical cause of hepatic encephalopathy and require immediate treatment to prevent worsening neurological decline.
• Total Bilirubin 2.0 mg/dL: While elevated bilirubin suggests cholestasis and impaired liver clearance, it leads to jaundice rather than mental status changes. It reflects liver dysfunction but is not the key factor in encephalopathy development.