During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

Hold the client's morning dose of lactulose:

Assess the client's hand movements with arms extended.

Encourage the client to ambulate in the hallway.

Compare current mental status findings with those from previous shifts.

Contact the health care provider to request a blood draw for ammonia level.

Answer and Explanation

Correct Answer : B,D,E

Rationale:

A. Lactulose is a first-line treatment for hepatic encephalopathy, used to reduce ammonia levels. Holding the medication could worsen the client’s mental status and precipitate further encephalopathy.

B. This is an assessment for asterixis (“liver flap”), a classic sign of hepatic encephalopathy. Evaluating neuromuscular function helps determine the severity of encephalopathy and guides clinical decisions regarding treatment and discharge readiness.

C. The client is sleepy and confused, indicating impaired cognition and risk for falls. Ambulation is unsafe until mental status improves and the patient is able to follow instructions and maintain balance.

D. Monitoring changes in mental status is essential in hepatic encephalopathy because subtle declines can signal worsening disease or precipitating factors such as infection, gastrointestinal bleeding, or electrolyte imbalance. Trend comparison guides timely intervention.

E. Although ammonia levels do not always correlate perfectly with severity of encephalopathy, they are commonly used to assess and monitor treatment response and can help identify the need for adjustments in therapy such as lactulose or rifaximin dosing.

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Correct Answer is A

Explanation

Rationale:

A. Alcohol is a major precipitating factor for acute pancreatitis and can trigger recurrent episodes. Abstaining from alcohol is the most important lifestyle modification to prevent further pancreatic injury, complications, and hospitalizations. This instruction directly addresses the underlying cause and is essential for long-term health.

B. While stress management can support overall well-being, it does not directly prevent or treat pancreatitis. Avoiding stress is not a primary intervention for preventing recurrence of acute pancreatitis.

C. Smoking cessation is important for general health and reduces the risk of pancreatic cancer, but it is secondary to alcohol abstinence in the context of acute pancreatitis management.

D. Pancreatic enzyme replacement therapy is typically indicated for chronic pancreatitis when exocrine insufficiency develops, not for acute pancreatitis. Teaching enzyme administration is not the priority at discharge for an acute episode.

A. Pruritus B. Arthralgia C. Polyphagia D. Skin abrasions

Correct Answer is D

Explanation

Rationale:

A. Pruritus (itching) is a common symptom in viral hepatitis due to bile salt accumulation in the skin resulting from impaired liver function. Itching often worsens at night and can significantly affect comfort. This is an expected finding.

B. Joint pain or arthralgia can occur in viral hepatitis, particularly in hepatitis B and C, due to immune-mediated inflammatory responses. This symptom is consistent with viral infection and liver inflammation.

C. Clients with viral hepatitis may experience anorexia or decreased appetite, but polyphagia (excessive hunger) is not typically associated with viral hepatitis. However, metabolic changes may sometimes alter appetite in early or resolving stages. This is less common but not the most unrelated finding.

D. Skin abrasions are not a direct manifestation of viral hepatitis. They may occur incidentally from trauma or other conditions but are unrelated to liver infection or its typical clinical features. This makes skin abrasions the finding not expected in viral hepatitis.

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During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides discharge teaching to the client diagnosed with acute pancreatitis. Which instruction is most important for the nurse to give the client?

Correct Answer is A

Explanation

The nurse assesses a client being evaluated for viral hepatitis. Which finding is not expected in viral hepatitis?

Correct Answer is D

Explanation

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