A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities.

Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Stage 4

Stage 3

Stage 1

Stage 2

Answer and Explanation

The Correct Answer is A

Choice A reason:

This presentation of hepatic encephalopathy includes severe manifestations, such as profound confusion, difficulty in arousal, and the presence of rigidity, indicating advanced neurological impairment. This places the patient in Stage 4, which is the most severe stage of hepatic encephalopathy.

Choice B reason:

Stage 3 is characterized by severe symptoms, such as drowsiness, anxiety, seizures, severe personality changes, confused speech, and shaky hands.

Choice C reason:

Stage 1 is characterized by mild symptoms, such as difficulty thinking, personality changes, poor concentration, and problems with handwriting.

Choice D reason

Stage 2 is characterized moderate symptoms, such as confusion, forgetfulness, poor judgment, and a musty or sweet breath odor.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:

Gallstones are a common cause of acute pancreatitis, as they can obstruct the pancreatic duct and lead to inflammation.

Choice B reason:

While diabetes mellitus can be a risk factor for pancreatitis, it is not specific to acute pancreatitis.

Choice C reason:

Chronic obstructive pulmonary disease (COPD) is not directly related to acute pancreatitis.

Choice D reason:

Hypolipidemia (low blood lipid levels) is not a common risk factor for acute pancreatitis.

A. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Withdraw the NG tube 3 to 5 cm and reattempt aspiration.

Correct Answer is B

Explanation

Choice A reason:

Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.

Choice B reason:

This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.

Choice C reason:

Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.

Choice D reason:

Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Correct Answer is A

Explanation

A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

Correct Answer is B

Explanation

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

A nurse is caring for a client who has acute pancreatitis. Exhibits Complete the following sentence. When prioritizing client needs, the nurse should first address the dropdown followed by dropdown

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?

The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?