What is the major cause of encephalopathy in cirrhosis?
Portal hypertension
Ascites
High ammonia levels
Vitamin K deficiency
The Correct Answer is C
A. Portal hypertension leads to complications like varices and ascites but is not the direct cause of encephalopathy.
B. Ascites is a fluid accumulation in the abdomen related to portal hypertension and low albumin, not directly linked to altered mental status.
C. High ammonia levels are the primary cause of hepatic encephalopathy in cirrhosis. The damaged liver is unable to effectively convert ammonia to urea, resulting in ammonia buildup in the blood, which affects brain function and leads to confusion, lethargy, or even coma.
D. Vitamin K deficiency contributes to bleeding problems, not encephalopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Clients with chronic renal failure often need dietary restrictions (e.g., low protein, low sodium, low potassium, fluid control) to reduce kidney workload and manage symptoms.
B. Monitoring and correcting imbalances in electrolytes like potassium, sodium, calcium, and fluid volume is a critical part of nursing care in chronic kidney disease.
C. When kidney function deteriorates significantly, dialysis becomes necessary to remove waste products and excess fluids from the blood.
D. Chronic renal failure patients are often unable to excrete sodium and potassium properly, so infusing them continuously would likely worsen electrolyte imbalances and lead to dangerous complications such as hyperkalemia or fluid overload. This is not a standard treatment.
Correct Answer is A
Explanation
A. This is the priority intervention to address powerlessness. Involving the client in planning promotes autonomy, empowerment, and a sense of control over their own care — which directly counters feelings of powerlessness associated with chronic, life-altering illness like ESRD.
B. While helpful for organization and adherence, this is not priority in addressing emotional or psychological issues like powerlessness. It is more of a supportive or logistical intervention.
C. This is a clinical management issue related to renal diet, not a direct intervention for powerlessness.
D. clients with ESRD typically require sodium restriction, not an increase, to manage fluid retention and hypertension.
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