A nurse is caring for an older adult patient who has just been admitted to the intensive care unit with a diagnosis of confusion/delirium.The patient has an end-stage liver failure diagnosis with increasing ascites.
Their spouse Questions the nurse about the patient’s mental status because they state that the patient is usually lucid. Which of the following is likely the contributing factor for the admitting diagnosis?

This is likely related to new-onset dementia.

This is likely related to new-onset schizophrenia.

This is likely related to new-onset hepatic encephalopathy.

This is likely related to a new-onset UTI.

Answer and Explanation

The Correct Answer is C

Choice C rationale
Hepatic encephalopathy is a condition that can cause confusion or delirium in patients with end-stage liver disease and increasing ascites. It occurs when the liver is unable to remove toxins from the blood, such as ammonia, which can then accumulate in the brain and affect mental function. This condition is common in patients with cirrhosis or end-stage liver disease, and can manifest as confusion, changes in sleep patterns, mood alterations, and, in severe cases, coma.
Choice A rationale
While dementia can cause confusion and changes in mental status, it is typically a progressive condition that develops over time. In the context of a patient with end-stage liver failure and

increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice B rationale
Schizophrenia is a chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It is not typically associated with end-stage liver disease or ascites. In the context of a patient with end-stage liver failure and increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice D rationale
While a urinary tract infection (UTI) can cause confusion, especially in older adults, it would not typically be the primary suspect in a patient with end-stage liver failure and increasing ascites. In such a patient, hepatic encephalopathy is a more likely cause of confusion or delirium.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
The effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis can be evaluated by observing the patient’s stool. Pancreatic enzyme replacement therapy (PERT) is used to improve digestion and absorption of nutrients in patients with pancreatic insufficiency, a common complication of chronic pancreatitis. One of the primary goals of PERT is to reduce steatorrhea, or fatty stools, which is a common symptom of pancreatic insufficiency. Therefore, observing changes in the patient’s stool, such as a reduction in fat content, can help evaluate the effectiveness of PERT567.
Choice B rationale
While saliva plays a role in the initial stages of digestion, it is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in saliva are not indicative of the effectiveness of this therapy.
Choice C rationale
Nasal mucus is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in nasal mucus are not indicative of the effectiveness of this therapy.
Choice D rationale
Urine is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in urine are not indicative of the effectiveness of this therapy.

A. Document the bowel sounds as hypoactive B. Administer prescribed drugs for constipation C. Review dietary intake for the past 24 hours D. Continue to listen for at least another 60 seconds

Correct Answer is D

Explanation

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which body substance should the nurse observe to evaluate the effectiveness of pancreatic enzyme replacement for a patient with chronic pancreatitis?

Correct Answer is A

Explanation

The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

Correct Answer is D

Explanation

A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following information should the nurse include in the teaching?

What effect does chronic exposure to ultraviolet (UV) rays have on the skin that increases the risk for skin cancer?

A nurse is assessing a postoperative client who has anemia due to excessive blood loss during surgery. What findings should the nurse expect?

A nurse is providing care for a patient who had a stroke and is experiencing difficulty swallowing. Which of the following complications should the nurse monitor for in this patient?

A nurse is educating a client who has recently been diagnosed with gastroesophageal reflux disease (GERD). The client inquires about foods to avoid. Which food should the nurse advise the client to avoid?

A nurse is caring for a patient who has cirrhosis of the liver and is having difficulty eliminating alcohol consumption because many of their friends drink alcohol socially. Which of the following steps should the nurse include to motivate the patient to change?

A nurse is caring for a patient newly diagnosed with hepatitis. Which nurse response best explains how a person can contract the virus?

A nurse is educating a patient with diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the patient?