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A nurse is caring for a newly admitted client.

Exhibits
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

Answer and Explanation

The Correct Answer is []

Rationale:

  • Potential Condition: The client with cirrhosis shows elevated ammonia (236 mcg/dL), confusion, agitation, and disorientation, which are classic findings of hepatic encephalopathy.
  • Actions to Take:
    • Lactulose is given to lower ammonia levels by promoting its excretion through the stool.
    • Assessing for asterixis (flapping tremor of the hands) is key in identifying worsening encephalopathy.
  • Parameters to Monitor:
    • Neurologic status (orientation, cognition, responsiveness) should be monitored closely to evaluate improvement or deterioration.
    • Safety measures are essential because confusion and agitation increase the client’s risk for falls and injury.


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Related Questions

Correct Answer is B

Explanation

Rationale:
A. Delaying discussion until after signing the consent form does not address the client’s immediate anxiety or provide needed education.

B. Providing information about sedation reassures the client that discomfort during the colonoscopy will be minimized and helps reduce anxiety. It is accurate, therapeutic, and informative.

C. Acknowledging the recommendation without addressing the anxiety does not provide reassurance or information about pain management.

D. While humorous, this comment does not address the client’s concern about pain and is not considered a therapeutic response.

Correct Answer is C

Explanation

Rationale:
A. Increasing hydration is important for preventing dehydration but does not restore gut flora.
B. Doxycycline is an antibiotic and would worsen disruption of gut microbiota.
C. Lactobacillus acidophilus (a probiotic) helps restore normal intestinal flora balance after antibiotic-associated diarrhea.
D. Psyllium husk is a fiber supplement that aids in bowel regularity but does not restore microbial balance.

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