A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
Asterixis
Change in orientation
Anorexia
Ascites
Fetor hepaticus
Correct Answer : A,B,E
Choice A reason: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, often seen in hepatic encephalopathy as a result of altered brain function.
Choice B reason: A change in orientation, including confusion and altered consciousness, is a hallmark of hepatic encephalopathy, reflecting the brain's impaired ability to process information.
Choice C reason: Anorexia may be present in cirrhosis, but it is not a specific indicator of hepatic encephalopathy.
Choice D reason: Ascites is a common complication of cirrhosis due to portal hypertension but is not a direct indicator of hepatic encephalopathy.
Choice E reason: Fetor hepaticus, a musty odor of the breath, is a distinctive symptom of hepatic encephalopathy caused by the presence of mercaptans in the breath as the liver fails to break down sulfur-containing amino acids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Dizziness and pallor are common vasomotor symptoms of early dumping syndrome. They result from the rapid shift of fluid into the intestine, leading to a decrease in blood volume and a temporary decrease in blood pressure.
Choice B reason: Abdominal cramping and pain are gastrointestinal symptoms of dumping syndrome but are not specifically vasomotor manifestations. They occur due to the rapid entry of hyperosmolar contents into the small intestine.
Choice C reason: Bradycardia is not typically a symptom of dumping syndrome. Instead, tachycardia is more commonly observed due to the body's response to the rapid changes in the gastrointestinal tract and blood volume.
Choice D reason: Double vision and chest pain are not typical symptoms of dumping syndrome. These symptoms may indicate other medical conditions and should be evaluated separately.
Correct Answer is B
Explanation
Choice A reason:While sharing needles can transmit hepatitis, it is more commonly associated with hepatitis B and C, not hepatitis A.
Choice B reason:Eating shellfish from contaminated water is a well-known route of transmission for hepatitis A, aligning with the client's symptoms.
Choice C reason:Blood transfusions were a risk for hepatitis transmission in the past, but since the 1990s, blood products are screened for hepatitis, making this an unlikely source.
Choice D reason:Unprotected sex can be a route of transmission for hepatitis, but hepatitis A is more commonly spread through ingestion of contaminated food or water, not sexual contact.
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