What is the major cause of encephalopathy in cirrhosis?

Portal hypertension

Ascites

High ammonia levels

Vitamin K deficiency

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. The PCA pump allows the patient to self-administer medication within safe limits set by the provider.
B. If the PCA is not effectively managing pain, the nurse needs to be informed to reassess and adjust the plan.
C. The patient can press the button to receive a controlled dose of analgesic.
D. This statement indicates the client does not understand the purpose of a PCA pump, which is designed to eliminate the need to call a nurse for each dose. This response signals the need for further teaching.

A. The client with an H/H (hemoglobin and hematocrit) of 12.8 and 38. B. The client who does not have a bruit or thrill in the fistula C. The client who is complaining of fatigue and headache. D. The client who is complaining of nausea.

Correct Answer is B

Explanation

A. The client with an H/H of 12.8 and 38 has lab values within acceptable range for a dialysis patient, especially since anemia is common in this population. This client is stable and does not require immediate assessment.
B. The client who does not have a bruit or thrill in the fistula is the priority. A lack of bruit or thrill may indicate that the arteriovenous (AV) fistula is clotted or not functioning, which is a critical issue. This compromises the client's ability to receive dialysis and requires urgent evaluation.
C. The client who is complaining of fatigue and headache may be experiencing symptoms related to uremia or hypertension, but these are not immediately life-threatening and can be addressed after checking the fistula issue.
D. The client who is complaining of nausea might be experiencing symptoms of fluid overload or uremia, but again, this is less urgent than a potentially non-functioning dialysis access site.

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What is the major cause of encephalopathy in cirrhosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client statement indicates to the nurse the need for further education regarding the use of a patient-controlled analgesia (PCA) pump? Select one:

Correct Answer is D

Explanation

The nurse in a dialysis unit is making rounds on clients. Which client should the nurse assess first?

Correct Answer is B

Explanation

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