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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: A BUN level of 20 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk of AKI.

Choice B reason: Serum Osmolality of 290 mOsm/kg H2O is within the normal range (275-295 mOsm/kg H2O) and does not suggest an increased risk of AKI.

Choice C reason: A Magnesium level of 2.0 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not indicate an increased risk of AKI.

Choice D reason: An elevated serum creatinine level, such as 1.8 mg/dL, indicates decreased kidney function and is a risk factor for AKI, especially post-MI where the kidneys may be vulnerable due to reduced cardiac output and potential nephrotoxic interventions.

A. Bubbling of the water in the water seal chamber with exhalation B. Crepitus in the area above and surrounding the insertion site C. Movement of the trachea toward the unaffected side D. Eyelets are not visible

Correct Answer is B

Explanation

Choice A reason:Bubbling in the water seal chamber with exhalation can be normal, indicating that air is being evacuated from the pleural space.

Choice B reason:Crepitus, or subcutaneous emphysema, can indicate that air is leaking into the tissue around the chest tube site, which is a serious complication that requires immediate attention.

Choice C reason:

Movement of the trachea toward the unaffected side can indicate tension pneumothorax, a life-threatening condition that also requires immediate attention.

Choice D reason:If the eyelets of the chest tube are not visible, it may simply mean that the tube is inserted fully, which is not an immediate cause for concern unless other symptoms are present.

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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).

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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