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.

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Correct Answer is B

Explanation

Choice A reason:

While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.

Choice B reason:

This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.

Choice C reason:

Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.

Choice D reason:

Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.

A. "The only time I flush my tube is when I'm putting in medications." B. "I clean my stoma twice a day with alcohol." C. "I try to stay still most of the time to avoid dislodging my tube." D. "I flush my tube with water before and after each of my medications."

Correct Answer is D

Explanation

Choice A reason:

Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.

Choice B reason:

Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.

Choice C reason:

While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube

maintenance.

Choice D reason:

Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the

tube correctly.

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

Correct Answer is B

Explanation

The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

Correct Answer is D

Explanation

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A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?

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