A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?

Rationale:

A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.

B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.

C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.

D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.

Rationale for correct choices

• Report to the provider immediately if a dry cough develops: ACE inhibitors or similar antihypertensive medications can cause a persistent dry cough as a side effect. Early reporting allows the provider to evaluate the need for medication adjustment or substitution to prevent further complications, such as noncompliance or worsening respiratory symptoms.

• Report to the provider immediately if the client experiences muscle aches: Muscle aches or myalgia can indicate statin-induced myopathy or rhabdomyolysis, particularly with elevated LDL and prescription of statins such as rosuvastatin. Early detection prevents severe muscle breakdown, renal impairment, or other complications.

Rationale for incorrect choices

• Increase sodium intake: The client has hypertension, and increasing sodium intake would exacerbate elevated blood pressure and increase the risk of cardiovascular complications, including heart failure and stroke. Sodium restriction is essential to support blood pressure control and overall cardiovascular health.

• Take rosuvastatin only in the morning: Rosuvastatin can be taken at any time of day, unlike some other statins that are recommended in the evening. Restricting it to the morning is unnecessary and may reduce adherence if it conflicts with the client’s routine. Emphasis should be on consistent daily intake rather than timing.