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
-
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:
-
Administer lactulose: Helps lower serum ammonia by promoting its excretion via the GI tract.
-
Assess for asterixis: A classic sign of hepatic encephalopathy characterized by a flapping tremor of the hands.
Parameters to Monitor:
-
Neurologic status: To detect changes in mental status or worsening encephalopathy.
-
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 A
Explanation
A. The patient requires painful stimuli to elicit a response and has no purposeful movement: This indicates a severe decrease in consciousness where the patient is minimally responsive, unable to respond to verbal stimuli, and shows no purposeful movement. It reflects significant brain dysfunction and is often seen in severe brain injury or coma.
B. The patient is drowsy but responds to verbal stimuli appropriately: This describes mild to moderate impairment of consciousness, where the patient is lethargic but still able to respond meaningfully to verbal commands, indicating a less severe condition.
C. The patient responds to commands but is slow to do so: A slowed response suggests some cognitive or neurological impairment but not a severe decrease in consciousness. The patient remains alert enough to follow instructions, albeit slowly.
D. The patient can follow simple commands like "open your eyes": This shows the patient is conscious and able to interact, reflecting a mild or normal level of consciousness rather than severe impairment.
Correct Answer is C
Explanation
A. Inflammation of the spinal cord: viral infection: This describes myelitis, which specifically affects the spinal cord, not encephalitis, which involves brain tissue inflammation.
B. A tumor of the brain: A brain tumor is a neoplastic growth and does not describe encephalitis, which is an inflammatory condition of the brain.
C. Inflammation of the brain tissue; viral infection: Encephalitis is inflammation of the brain parenchyma, most commonly caused by viral infections such as herpes simplex virus, which directly infect and inflame brain tissue.
D. Infection of the meninges: bacterial infection: This describes meningitis, an infection of the protective membranes surrounding the brain and spinal cord, not encephalitis, which affects the brain tissue itself.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.