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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

Correct Answer is ["1.9"]

Explanation

Calculation:

Dosage ordered = 7.6 mg

Drug concentration = 4 mg/mL

7.6 mg / 4 mg/mL = 1.9 mL

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 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

A child is to receive dexamethasone (Decadron) intravenously at the ordered dosage of 7.6 mg. The drug concentration in the vial is 4 mg/mL. The nurse should administer how many ml?

Correct Answer is ["1.9"]

Explanation

A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test?

A client is prescribed lansoprazole 15 mg PO once a day. At which of the following times should the nurse administer the medication?

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?

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 with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?

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?

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client s understanding of the teaching? (Select all that apply)

Give Ceclor 45mg/kg/day p.o. in 3 divided doses for a patient who weighs 66 pounds. A 75mL stock medication is labeled Ceclor 125mg/mL. How many mLs would the nurse administer per dose? Units in mL. (Please record your exact answer)