A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities.

Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Stage 4

Stage 3

Stage 1

Stage 2

Answer and Explanation

The Correct Answer is A

Choice A reason:

This presentation of hepatic encephalopathy includes severe manifestations, such as profound confusion, difficulty in arousal, and the presence of rigidity, indicating advanced neurological impairment. This places the patient in Stage 4, which is the most severe stage of hepatic encephalopathy.

Choice B reason:

Stage 3 is characterized by severe symptoms, such as drowsiness, anxiety, seizures, severe personality changes, confused speech, and shaky hands.

Choice C reason:

Stage 1 is characterized by mild symptoms, such as difficulty thinking, personality changes, poor concentration, and problems with handwriting.

Choice D reason

Stage 2 is characterized moderate symptoms, such as confusion, forgetfulness, poor judgment, and a musty or sweet breath odor.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Choice A reason:

This statement demonstrates the client's understanding of the need to reduce intake of caffeine and spicy foods, which can exacerbate symptoms of hiatal hernia.

Choice B reason:

This statement shows the client's awareness of the importance of maintaining a healthy weight, which can help manage hiatal hernia symptoms.

Choice C reason:

This statement is not related to the dietary recommendations for hiatal hernia.

Choice D reason:

Limiting fluid intake can help prevent excessive stomach distension, which may aggravate hiatal hernia symptoms.

A. Keep the patient in a low Fowler's position when at rest. B. Connect the tube to continuous wall suction when not in use. C. Confirm placement of the tube prior to each medication administration. D. Have the patient sip cool water to stimulate saliva production.

Correct Answer is C

Explanation

Choice A reason:

Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.

Choice B reason:

Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.

Choice C reason:

Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.

Choice D reason:

Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.

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A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client s understanding of the teaching? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?

Correct Answer is C

Explanation

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A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?