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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Correct Answer is D

Explanation

Choice A reason:

Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.

Choice B reason:

Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.

Choice C reason:

While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube

maintenance.

Choice D reason:

Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the

tube correctly.

A. Assess for signs of infection. B. Assess for a patent airway. C. Assess ability to clear oral secretions. D. Assess for ability to communicate.

Correct Answer is B

Explanation

Choice A reason:

While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.

Choice B reason:

This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.

Choice C reason:

Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.

Choice D reason:

Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.

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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

The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

Correct Answer is D

Explanation

A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Correct Answer is B

Explanation

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