A nurse is caring for a newly admitted client.
A nurse notes the client's condition and initiates the following action.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Hepatic Encephalopathy
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The client has very high ammonia levels (236 mcg/dL), elevated liver enzymes, and low albumin, all pointing toward hepatic encephalopathy. Additional signs include a history of alcohol abuse, cirrhosis, and altered liver function, which commonly contribute to ammonia accumulation and neurotoxicity.
Actions to Take:
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Administer lactulose: Helps lower serum ammonia by promoting its excretion via the GI tract.
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Assess for asterixis: A classic sign of hepatic encephalopathy characterized by a flapping tremor of the hands.
Parameters to Monitor:
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Neurologic status: To detect changes in mental status or worsening encephalopathy.
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Safety measures: Clients with hepatic encephalopathy are at high risk for confusion, falls, and injury, necessitating close supervision and safety interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nausea: Nausea can occur with peptic ulcers, particularly if gastric emptying is delayed or if inflammation affects the stomach lining. However, it is not the most common or defining symptom.
B. Pain in the epigastric region: Epigastric pain is the hallmark symptom of peptic ulcers. It is typically described as burning or gnawing and may occur between meals or at night, often relieved by eating or antacids.
C. Melena: Melena, or black tarry stools, can occur if the ulcer bleeds, but this is more of a complication than a routine symptom. It indicates gastrointestinal bleeding and requires urgent evaluation.
D. Decreased appetite: Appetite changes may occur, especially if eating exacerbates pain in gastric ulcers. However, decreased appetite is not as frequent or specific a symptom as epigastric pain.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. May be idiopathic: In many cases, especially central precocious puberty, no identifiable underlying cause is found. This is referred to as idiopathic precocious puberty and is a common diagnosis, particularly in girls.
B. Peripheral precocious puberty is independent of gonadotropin release from the pituitary gland: Peripheral (or gonadotropin-independent) precocious puberty occurs due to hormone secretion from sources other than the pituitary, such as adrenal tumors or ovarian cysts.
C. Central precocious puberty is caused by premature activation of the hypothalamic-pituitary-gonadal (HPG) axis: This is the most common form and involves early activation of the normal puberty pathway via the HPG axis.
D. It is defined as the onset of secondary sexual characteristics before age 8 in girls and age 9 in boys: This is the widely accepted medical definition of precocious puberty based on chronological age for the appearance of secondary sexual characteristics.
E. Tall stature during childhood is a common feature, but final adult height may be shorter than expected without treatment: Early growth spurts can lead to early closure of growth plates, resulting in reduced adult height if untreated.
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