A client has been administered lactulose for several days.
Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?
Improved mental status.
Increase in urine output.
Reduction in number of liquid stools.
Ability to ambulate independently.
The Correct Answer is A
Choice A rationale:
Lactulose directly addresses the primary cause of hepatic encephalopathy, which is the accumulation of ammonia in the blood. Ammonia is a neurotoxin that can impair brain function, leading to confusion, lethargy, and even coma. Lactulose works by trapping ammonia in the colon, where it can be safely excreted in the stool. This decrease in ammonia levels in the blood allows for the improvement of mental status.
Studies have consistently shown that lactulose therapy can significantly improve mental function in patients with hepatic encephalopathy. This improvement is often seen within a few days of starting treatment.
The nurse should assess the client's mental status regularly to monitor for improvement. This assessment should include evaluating the client's level of consciousness, orientation, attention, memory, and speech.
Improved mental status is a critical therapeutic goal in the treatment of hepatic encephalopathy. It allows patients to regain their independence and participate more fully in their care.
Choice B rationale:
While lactulose can cause diarrhea, which may lead to a slight increase in urine output, this is not the primary therapeutic response that the nurse should expect.
The increase in urine output is typically secondary to the diarrhea and does not directly reflect a reduction in ammonia levels or improvement in mental status.
Choice C rationale:
Lactulose does cause diarrhea, which is a common side effect of the medication.
However, the goal of lactulose therapy is not to reduce the number of liquid stools but rather to trap ammonia in the colon and promote its excretion.
The nurse should monitor the client's stool frequency and consistency to ensure that they are not experiencing excessive diarrhea, which could lead to dehydration and electrolyte imbalances.
Choice D rationale:
While improved mental status may eventually lead to improved mobility, it is not the most immediate or direct therapeutic response that the nurse should expect from lactulose therapy.
The ability to ambulate independently is more likely to be a long-term goal of treatment, rather than an immediate response to lactulose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Pneumonia is the most likely diagnosis given the rapid development of pulmonary infiltrates within a 24-hour period. Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi. It typically presents with symptoms such as fever, cough, shortness of breath, and chest pain. The presence of pulmonary infiltrates on imaging studies, such as a chest X-ray, is a key diagnostic feature of pneumonia.
The distribution of the infiltrates, involving the lower lobes with a predominance on the right side, is also consistent with pneumonia. This is because the lower lobes are more susceptible to pneumonia due to their anatomy and gravity.
The absence of active processes on Day 1 makes other diagnoses less likely. For example, tuberculosis typically develops more slowly over weeks or months, and bronchitis usually does not cause pulmonary infiltrates.
Pulmonary embolism can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.
Choice B rationale:
Tuberculosis is a chronic infection that typically develops slowly over weeks or months. It is less likely to cause rapid development of pulmonary infiltrates as seen in this case.
Tuberculosis often involves the upper lobes of the lungs, and it may be associated with other symptoms such as fever, night sweats, and weight loss.
Choice C rationale:
Bronchitis is an inflammation of the bronchi, the large airways that carry air to the lungs. It typically causes a cough, but it does not usually cause pulmonary infiltrates.
Bronchitis is often caused by a virus, and it usually resolves on its own within a few weeks.
Choice D rationale:
Pulmonary embolism is a blockage of a pulmonary artery, one of the blood vessels that carries blood to the lungs. It can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.
Pulmonary embolism is often caused by a blood clot that travels from a vein in the leg to the lungs.
Correct Answer is ["B","C","E","F"]
Explanation
B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Rationale:
Hypoxemia: Patients who have undergone cholecystectomy are at risk for developing hypoxemia due to various factors, including:
Atelectasis: Collapsed lung tissue can impair gas exchange, leading to low oxygen levels in the blood.
Pneumonia: A potential post-operative complication that can cause inflammation and fluid buildup in the lungs, hindering oxygen uptake.
Pain: Post-surgical pain can inhibit deep breathing and coughing, which are essential for maintaining adequate lung function.
Oxygen Therapy: Supplementing oxygen helps to increase oxygen saturation and improve overall tissue oxygenation, reducing the strain on the heart and other organs.
Oxygen Saturation Goal: Maintaining oxygen saturation at or above 95% ensures that the patient's tissues are receiving sufficient oxygen to meet their metabolic needs.
C. Stat 2 views chest x-ray.
Rationale:
Chest X-ray: A valuable diagnostic tool that can visualize the lungs and surrounding structures, aiding in the assessment of: Atelectasis: Appears as areas of increased density on the x-ray, indicating collapsed lung tissue.
Pneumonia: May present as consolidation (solid white areas) or infiltrates (patchy areas of increased density) on the x-ray. Pleural effusion: Fluid accumulation in the pleural space, which can impair lung expansion and gas exchange.
Pneumothorax: Presence of air in the pleural space, which can cause lung collapse and respiratory distress.
Early Detection: Prompt identification of respiratory complications through chest x-ray allows for timely interventions and prevents further deterioration of the patient's condition.
E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
Rationale:
CBC: Assesses for signs of infection or inflammation, including:
Elevated white blood cell count (leukocytosis) Increased neutrophils (neutrophilia)
Anemia (low red blood cell count)
BMP: Evaluates electrolyte and kidney function, which can be affected by infections and post-operative complications.
Blood Cultures: Determines the presence of bacteria in the bloodstream, allowing for identification of the causative organism and guiding appropriate antibiotic therapy.
F. Start the patient on antibiotic therapy.
Rationale:
Infection Risk: The patient's history of cholangitis and recent surgery increase the risk of infection. Prophylactic Antibiotics: Often administered after cholecystectomy to prevent post-operative infections.
Early Intervention: Prompt initiation of antibiotic therapy is crucial in managing infections and preventing serious complications such as sepsis.
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