The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

Bradycardia

Asterixis

Fever

Melena

Answer and Explanation

The Correct Answer is B

A) Bradycardia is not typically associated with hepatic encephalopathy.

B) Asterixis is a characteristic finding in hepatic encephalopathy, known as "flapping tremor," indicating neuromuscular irritability due to elevated blood ammonia levels.
C) Fever is not a common direct symptom of hepatic encephalopathy.

D) Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.

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Correct Answer is B

Explanation

A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.

A. Assess level of consciousness B. Assess for bleeding C. Measure abdominal girth D. Auscultate bowel sounds

Correct Answer is A

Explanation

A) Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B) The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C) This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D) While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.

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The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?

Correct Answer is B

Explanation

A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Correct Answer is A

Explanation

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