A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include?

Rationale:

• Hepatic encephalopathy: This is caused by the buildup of neurotoxins, particularly ammonia, due to impaired liver function. The client’s elevated ammonia level and history of chronic alcohol use and jaundice support this diagnosis. Early signs may include confusion and lethargy, progressing to coma if untreated.
• Uremic encephalopathy: This condition is caused by accumulation of urea and toxins due to kidney failure. There is no evidence in the case of renal impairment, such as elevated BUN or creatinine levels, making this diagnosis unlikely in the current context.
• Hypoglycemia: Low blood glucose can cause confusion or altered mental status, but this client’s symptoms and labs do not indicate hypoglycemia. There is no mention of a low glucose level, and the focus of concern is more aligned with liver failure than endocrine causes.

• Abdominal pain: Although abdominal pain is a relevant symptom in liver disease, it is nonspecific and not directly responsible for hepatic encephalopathy. It reflects general liver inflammation or ascites but does not cause neurologic symptoms on its own.
• Albumin 3.0 g/dL: Low albumin indicates reduced liver synthetic function and contributes to fluid shifts like ascites, but it is not neurotoxic. It does not directly cause hepatic encephalopathy or altered mental status.
• Ammonia 150 mcg/dL: This is a critically elevated value, more than double the normal upper limit. High ammonia levels are the most direct biochemical cause of hepatic encephalopathy and require immediate treatment to prevent worsening neurological decline.
• Total Bilirubin 2.0 mg/dL: While elevated bilirubin suggests cholestasis and impaired liver clearance, it leads to jaundice rather than mental status changes. It reflects liver dysfunction but is not the key factor in encephalopathy development.

Rationale:
A. Administer vasopressin to the client: Vasopressin helps control variceal bleeding by constricting splanchnic blood vessels. However, it cannot be safely or effectively administered until reliable IV access is confirmed, making it a secondary priority.

B. Request blood from blood bank: While the client may need transfusions to correct hypovolemia and blood loss, requesting blood is not the most immediate step. Before transfusion or medication, the nurse must ensure a functional IV line is available.

C. Verify that the client has adequate IV access: The priority in any hemorrhagic shock situation is to secure IV access to allow for fluid resuscitation, medication administration, and blood transfusion. Without IV access, no other interventions can be effectively implemented.

D. Insert an indwelling urinary catheter: Monitoring urine output is important in assessing renal perfusion and fluid status. However, this action does not address the immediate circulatory needs of the client and can be done after resuscitative access is secured.