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.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Disequilibrium syndrome is characterized by headache, nausea, and agitation, which can occur during or after hemodialysis, especially in the first few sessions as the body adjusts to the treatment².
Choice B reason: Septicemia would typically present with fever, chills, and hypotension, not specifically headache and agitation².
Choice C reason: Air embolism is a rare complication that would present with sudden respiratory distress, chest pain, and possibly hypotension, not just headache and agitation².
Choice D reason: Peritonitis is associated with abdominal pain and tenderness, fever, and possibly altered bowel movements, not the symptoms described².
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Hypoxemia, or low oxygen levels in the blood, is a primary indicator of ARF as the lungs are unable to adequately oxygenate the blood.
Choice B reason: Confusion can result from hypoxemia or hypercapnia (high carbon dioxide levels) as the brain is sensitive to changes in blood gas levels.
Choice C reason: Dyspnea, or difficulty breathing, is a hallmark symptom of ARF as the lungs struggle to maintain adequate gas exchange.
Choice D reason: Bradycardia, or a slow heart rate, is not typically associated with ARF. Tachycardia, or a fast heart rate, is more common as the body attempts to compensate for hypoxemia.
Choice E reason: Hypocarbia, or low carbon dioxide levels, can occur in ARF if the body is attempting to compensate for hypoxemia by hyperventilating.
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