A client has been administered lactulose for several days.
Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)

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.