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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This statement is correct. The laxative helps eliminate the barium contrast material from the body after a barium swallow procedure.
Choice B reason:
Simply stating that it is protocol does not provide the client with a clear understanding of the rationale for the laxative.
Choice C reason:
This statement does not accurately explain the purpose of the laxative after a barium swallow.
Choice D reason:
The laxative's primary purpose in this context is to aid in the elimination of barium, not to prevent magnesium absorption.
Correct Answer is B
Explanation
Choice A reason:
Sudden thirst, unrelieved by oral fluid administration, may indicate dehydration, but it is not specific to a recurrence of upper GI bleeding.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of upper GI bleeding and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to a recurrence of upper GI bleeding.
Choice D reason:
Tarry, foul-smelling stools (melena) are indicative of upper GI bleeding. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
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