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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
Choice B reason:
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis.
They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
Choice C reason:
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
Choice D reason:
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
Correct Answer is A
Explanation
Choice A reason:
This statement is correct. The laxative helps eliminate the barium contrast material from the body after a barium swallow procedure.
Choice B reason:
Simply stating that it is protocol does not provide the client with a clear understanding of the rationale for the laxative.
Choice C reason:
This statement does not accurately explain the purpose of the laxative after a barium swallow.
Choice D reason:
The laxative's primary purpose in this context is to aid in the elimination of barium, not to prevent magnesium absorption.
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