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 ["D"]
Explanation
A. Obtunded: Obtunded patients show decreased alertness and respond slowly to stimuli, often requiring repeated stimulation to maintain attention. This level of consciousness is more severe than confusion and typically involves reduced awareness.
B. Coma: Coma is a state of deep unconsciousness where the patient is unarousable and unresponsive to external stimuli. It is much more severe than confusion or disorientation and is unlikely in a patient who is still able to interact, even if confused.
C. Stupor: Stupor refers to a condition where the patient is mostly unresponsive and only responds to vigorous or painful stimuli. It is more severe than confusion and involves markedly diminished awareness.
D. Delirium: Delirium is characterized by acute onset of confusion, disorientation, impaired attention, and fluctuating levels of consciousness. It best matches the patient's symptoms of confusion, disorientation, and inability to focus.
E. Mild lethargy: Mild lethargy involves drowsiness and reduced energy but does not typically impair orientation or the ability to focus as severely as seen in this patient.
Correct Answer is D
Explanation
A. Increase their intake of cranberry juice and other fluids: While cranberry juice and increased fluids may help prevent or relieve mild urinary tract infections, the presence of blood in the urine (hematuria) and lower abdominal pain may indicate a more serious condition that requires professional evaluation rather than home remedies alone.
B. Wait and see if it goes away without treatment: Ignoring hematuria and pain can delay diagnosis and treatment of potentially serious conditions such as infections, stones, or other urinary tract problems. Prompt assessment is important to prevent complications.
C. Go to the emergency room right away: Unless symptoms are severe, such as uncontrollable pain, fever, or signs of systemic infection, immediate emergency care may not be necessary. However, timely medical evaluation is still essential.
D. Get an appointment with their family provider: This is the most appropriate advice because a healthcare provider can perform necessary assessments, such as history, physical exam, and diagnostic tests, to determine the cause of hematuria and pain and initiate appropriate treatment.
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