A nurse is caring for a client with advanced cirrhosis who has developed hepatic encephalopathy. What intervention is a priority for the nurse?
Administering a high-protein diet to support liver function
Administering lactulose to reduce ammonia levels
Administering sedatives to promote rest and relaxation
Administering iron supplements to address anemia
The Correct Answer is B
A) Incorrect. While protein is important, in the case of hepatic encephalopathy, reducing ammonia levels is the priority. A high-protein diet may exacerbate this condition.
B) Correct. Lactulose is a medication used to reduce ammonia levels in clients with hepatic encephalopathy, which is a complication of advanced cirrhosis.
C) Incorrect. Administering sedatives may worsen hepatic encephalopathy. The focus should be on reducing ammonia levels.
D) Incorrect. Administering iron supplements is not a priority in addressing hepatic encephalopathy. The focus should be on managing ammonia levels.
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Related Questions
Correct Answer is D
Explanation
A) Incorrect. While jaundice, abdominal pain, and fatigue can be seen in chronic hepatitis, they are not always present, and the presentation can vary widely among individuals.
B) Incorrect. Chronic hepatitis can present with noticeable symptoms, especially in the early stages, before it progresses to cirrhosis.
C) Incorrect. Chronic hepatitis primarily affects the liver, not the cardiovascular system.
D) Correct. Signs and symptoms of chronic hepatitis can vary widely among individuals, and some individuals may not exhibit noticeable symptoms, especially in the early stages.
Correct Answer is A
Explanation
A) Correct. Spider angiomas (vascular lesions on the skin), jaundice (yellowing of the skin and eyes), and ascites (accumulation of fluid in the abdomen) are indicative of advanced cirrhosis.
B) Incorrect. Mild fatigue and occasional abdominal discomfort may be present in cirrhosis, but they are not specific indicators of advanced disease.
C) Incorrect. Elevated liver enzymes and occasional nausea can be seen in cirrhosis, but they do not specifically indicate advanced stages.
D) Incorrect. Mild splenomegaly (enlarged spleen) and weight loss can occur in cirrhosis, but they are not as indicative of advanced disease as the combination of spider angiomas, jaundice, and ascites.
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