An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?

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. Place the affected leg in external rotation: External rotation of the leg can increase the risk of hip dislocation following a total hip arthroplasty. The leg should be maintained in a neutral or slightly abducted position to protect the joint.

B. Encourage the client to use the incentive spirometer every shift: Incentive spirometry should be used every 1 to 2 hours while awake to prevent postoperative complications like atelectasis. Using it only once per shift is not sufficient.

C. Instruct the client to lean forward when rising from a chair: Leaning forward while rising increases hip flexion beyond 90 degrees, which places stress on the hip joint and raises the risk of dislocation. Clients should keep their hips higher than their knees and use armrests for support.

D. Maintain abduction of the affected extremity: Keeping the leg in abduction helps prevent dislocation of the prosthetic joint by maintaining proper alignment. This can be achieved using an abduction pillow or wedge between the legs.