A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the client's intake of protein.

Restrict the client's intake of fluids.

Administer vitamin K

Administer diuretics.

Answer and Explanation

The Correct Answer is A

A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.

B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.

C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.

D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.

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Correct Answer is D

Explanation

A. Suctioning the nostril is not appropriate as it could exacerbate potential cerebrospinal fluid (CSF) leakage or cause further injury.

B. Asking the client to blow their nose could increase intracranial pressure and potentially worsen a skull fracture or CSF leak.

C. While notifying the physician is important, the initial step should be to determine whether the clear drainage is CSF, which has specific implications.

D. Testing the drainage for glucose is crucial because a positive glucose test indicates that the fluid is likely CSF, which can signal a skull fracture and possible brain injury. This finding requires immediate medical evaluation to manage potential complications like infections or worsening of the fracture.

A. Pancrelipase 500 units/kg PO three times daily with meals B. Initiate a low-residue diet C. Pantoprazole 80 mg IV bolus twice daily D. Ambulate twice daily E. Ambulate twice daily

Correct Answer is C

Explanation

A. Pancrelipase is used for enzyme replacement therapy in chronic pancreatitis, not acute pancreatitis. In acute pancreatitis, the focus is on rest and managing symptoms rather than enzyme supplementation.

B. Initiating a low-residue diet is not appropriate during the acute phase of pancreatitis. Clients are typically NPO or on a clear liquid diet initially to allow the pancreas to rest and heal.

C. Pantoprazole is a proton pump inhibitor that reduces gastric acid production and is commonly used to prevent stress ulcers and manage symptoms in clients with acute pancreatitis. Reducing gastric acid helps in managing complications associated with pancreatitis.

D. Ambulation is generally encouraged once the client is stable but is not a primary prescription for acute pancreatitis. The initial focus is on managing symptoms and ensuring adequate rest.

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A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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