A nurse is caring for a newly admitted client.
A nurse notes the client's condition and initiates the following action.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Hepatic Encephalopathy
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The client has very high ammonia levels (236 mcg/dL), elevated liver enzymes, and low albumin, all pointing toward hepatic encephalopathy. Additional signs include a history of alcohol abuse, cirrhosis, and altered liver function, which commonly contribute to ammonia accumulation and neurotoxicity.
Actions to Take:
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Administer lactulose: Helps lower serum ammonia by promoting its excretion via the GI tract.
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Assess for asterixis: A classic sign of hepatic encephalopathy characterized by a flapping tremor of the hands.
Parameters to Monitor:
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Neurologic status: To detect changes in mental status or worsening encephalopathy.
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Safety measures: Clients with hepatic encephalopathy are at high risk for confusion, falls, and injury, necessitating close supervision and safety interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Presence of insulin autoantibodies that destroy beta cells in the pancreas: This describes the autoimmune process characteristic of Type 1 diabetes mellitus, where the immune system attacks pancreatic beta cells, leading to insulin deficiency.
B. Need for lifelong insulin injections: Lifelong insulin therapy is typically required in Type 1 diabetes due to absolute insulin deficiency. Many individuals with Type 2 diabetes can manage their condition initially with lifestyle changes and oral medications.
C. Increase of glucagon secretion from beta cells of the pancreas: Glucagon is secreted by alpha cells, not beta cells, in the pancreas. Dysregulation of glucagon contributes to hyperglycemia but is not a defining feature distinguishing Type 2 diabetes.
D. Resistance to insulin by insulin-sensitive tissues: Type 2 diabetes is primarily characterized by insulin resistance, where muscle, fat, and liver cells do not respond properly to insulin, leading to elevated blood glucose levels despite normal or increased insulin production. This resistance is a hallmark feature distinguishing it from Type 1 diabetes.
Correct Answer is A
Explanation
A. Decision-making, problem-solving, and planning: The frontal lobe is primarily responsible for higher-order executive functions such as reasoning, decision-making, problem-solving, judgment, and planning. It also plays a role in personality and voluntary motor control, especially through the prefrontal cortex and motor areas.
B. Vision and color recognition: These functions are associated with the occipital lobe, which is located at the back of the brain and specializes in processing visual input, including aspects like color, shape, and motion.
C. Language comprehension and memory: Language comprehension is primarily controlled by Wernicke’s area, which is located in the temporal lobe. Memory is also associated with the temporal lobe and the limbic system structures like the hippocampus.
D. Movement coordination and balance: These are functions of the cerebellum, which regulates fine motor control, coordination, balance, and posture—not the frontal lobe.
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