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
Explanation
A. Brain, blood, cerebrospinal fluid (CSF): These are the three main components within the cranial vault as described by the Monro-Kellie doctrine. The total volume of these components remains constant, and any increase in one must be offset by a decrease in another to prevent elevated ICP.
B. Cerebrospinal fluid (CSF), blood, oxygen: While CSF and blood are intracranial components, oxygen is not a physical substance occupying volume in the cranial cavity. It is transported within the blood and does not contribute to changes in ICP in terms of physical space.
C. Brain, cerebrospinal fluid (CSF), air: Air is not a normal component of the cranial cavity. The presence of air would indicate pathology, such as a skull fracture with pneumocephalus, which is abnormal and can contribute to increased ICP but is not a standard component.
D. Brain, blood, lymphatic fluid: While the brain and blood are correct components, the central nervous system, including the brain, does not have a conventional lymphatic system like other parts of the body. Waste products are primarily cleared by the glymphatic system, which utilizes CSF, rather than traditional lymphatic fluid.
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