A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the nest information to evaluate the client’s therapeutic response to the drug?

Fingerstick glucose.

Serum electrolytes and ammonia.

Stool color and character.

Serum hepatic enzymes.

Answer and Explanation

The Correct Answer is B

Lactulose is a medication commonly used in the management of hepatic encephalopathy. It works by reducing the absorption of ammonia in the gut, which is a toxin that can accumulate in the blood in patients with liver dysfunction.

Monitoring serum electrolytes and ammonia levels can help the nurse evaluate the eﬀectiveness of lactulose therapy. Elevated ammonia levels can indicate that the medication is not eﬀectively reducing ammonia absorption and may require adjustment in dose or frequency. Additionally, monitoring electrolyte levels can help detect any imbalances that may occur because of lactulose therapy.

Fingerstick glucose levels (option A) are not relevant to evaluating the therapeutic response of lactulose in hepatic encephalopathy.

Stool color and character (option C) may be monitored to assess the side eﬀects of lactulose, such as diarrhea, but are not the best assessments to evaluate therapeutic response.

Serum hepatic enzymes (option D) may be useful in assessing the severity of liver disease but are not the best assessment to evaluate the therapeutic response of lactulose in hepatic encephalopathy.

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Correct Answer is C

Explanation

Continuous rubbing of the back of the neck can be a side eﬀect of antipsychotic medication, known as acute dystonia. Benztropine is an anticholinergic medication that can eﬀectively treat acute dystonia. Therefore, the nurse should give a PRN prescription for benztropine to relieve the client's discomfort. Options a, b, and d do not address the underlying issue of acute dystonia and are not the best interventions for this particular situation.

A. Use stool softener as needed. B. Avoid ingestion of alcohol. C. Discontinue when spasms cease. D. Take medication with meals.

Correct Answer is C

Explanation

Baclofen is a muscle relaxant medication used to treat muscle spasticity, which is a condition that causes muscles to become stiﬀ and rigid. It works by reducing the activity of nerves in the brain and spinal cord that cause muscle spasms.

Option a, using stool softener as needed, is appropriate because baclofen can cause constipation as a side eﬀect.

Option b, avoiding ingestion of alcohol, is also appropriate because alcohol can increase the sedative eﬀects of baclofen and cause drowsiness or dizziness.

Option d, taking medication with meals, is recommended because it can help reduce stomach upset and nausea that may occur as a side eﬀect of the medication.

Option c, discontinuing the medication when spasms cease, is incorrect because muscle spasticity is a chronic condition, and baclofen is used to manage symptoms over a prolonged period. Discontinuing the medication abruptly can cause withdrawal symptoms and exacerbate the spasticity. Therefore, the nurse should educate the client to take the medication as prescribed by the healthcare provider and not discontinue it without medical advice.

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A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the nest information to evaluate the client’s therapeutic response to the drug?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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