A client with end-stage liver failure becomes increasingly confused and lethargic.
The nurse notes asterixis. Which intervention should the nurse anticipate?
Administer vitamin K.
Decrease protein intake.
Administer lactulose.
Restrict sodium intake.
The Correct Answer is C
The clinical presentation of asterixis and lethargy in liver failure indicates hepatic encephalopathy. Knowledge of nitrogenous waste metabolism and the pharmacological action of osmotic laxatives is necessary to address the buildup of neurotoxic ammonia levels within the systemic circulation.
Choice A rationale
Vitamin K is essential for synthesizing clotting factors II, VII, IX, and X in the liver. While liver failure causes coagulopathy, this intervention does not address the neurological symptoms caused by elevated ammonia or metabolic encephalopathy.
Choice B rationale
Historically, protein restriction was used to limit ammonia production. However, modern guidelines emphasize maintaining adequate protein intake to prevent muscle wasting and malnutrition, which can actually worsen the clinical outcomes and metabolic status in cirrhotic patients.
Choice C rationale
Lactulose is a synthetic disaccharide that acidifies colonic contents. This converts ammonia into ammonium, which is poorly absorbed and excreted via stool. It is the gold standard for reducing neurotoxic ammonia levels in hepatic encephalopathy.
Choice D rationale
Sodium restriction is primarily utilized to manage fluid retention and ascites in portal hypertension. While important for volume control, it does not directly impact the cerebral edema or neurotoxicity associated with the presence of asterixis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Neurological assessment using motor responses helps determine the level of brainstem involvement. This scenario requires applying knowledge of the Glasgow Coma Scale and motor pathways to distinguish between pathological posturing and more integrated, purposeful motor functions.
Choice A rationale
Purposeful movement indicates that the motor cortex or higher brain centers are successfully processing stimuli. Moving away from pain represents a significant improvement from decorticate posturing, which involves damage to the corticospinal tract and midbrain.
Choice B rationale
Decerebrate posturing involves rigid extension of the arms and legs, signifying deeper brainstem injury or herniation. This change indicates neurological deterioration rather than improvement, as it suggests the lesion has progressed lower into the pons.
Choice C rationale
Pupils that are fixed and dilated at 6 mm indicate loss of autonomic function and severe cranial nerve III compression. This is a sign of increasing intracranial pressure and brainstem failure, representing a critical clinical decline.
Choice D rationale
Flaccid paralysis is often the most severe motor finding, indicating a loss of all muscle tone and spinal reflex arcs. In the context of traumatic brain injury, this usually signals profound neurological collapse rather than recovery..
Correct Answer is A
Explanation
This scenario requires the application of electrocardiography interpretation skills to identify specific cardiac arrhythmias based on rhythm regularity, presence of P waves, and heart rate. Recognizing atrial fibrillation is essential for determining appropriate anticoagulation and rate control interventions for telemetry clients.
Choice A rationale
Atrial fibrillation is characterized by an irregularly irregular rhythm and a lack of discernible P waves. The rapid, disorganized electrical activity in the atria leads to ineffective pumping and increased risk for thromboembolic events or symptomatic palpitations.
Choice B rationale
Sinus tachycardia follows a regular rhythm with identifiable P waves preceding every QRS complex. The rate is typically between 101 and 150 beats per minute. This does not match the irregularly irregular rhythm or absent P waves described.
Choice C rationale
First degree heart block involves a delayed conduction through the atrioventricular node, resulting in a prolonged PR interval greater than 0.20 seconds. However, the rhythm remains regular with a 1 to 1 ratio of P waves to QRS.
Choice D rationale
Ventricular tachycardia presents as three or more consecutive premature ventricular contractions with a rate usually exceeding 100 per minute. It shows wide, bizarre QRS complexes and is typically a regular rhythm, which is inconsistent with this client strip.
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