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 ["A","B"]

Explanation

Choice A reason:

Anticholinergic medications: These are not a component of treatment for diverticular disease. Anticholinergic medications can reduce intestinal motility and cause dry mouth, constipation, and urinary retention, which can aggravate the diverticula and increase the risk of complications. The patient should avoid these medications unless prescribed by a doctor for another condition.

Choice B reason:

Increasing fiber intake is a common component of treatment for diverticular disease as it can help prevent constipation and reduce the risk of diverticulitis.

Choice C reason:

Reducing fat intake is also important in the treatment of diverticular disease, as a low-fat diet can help prevent further irritation of the colon.

Choice D reason:

This is not a component of treatment for diverticular disease. On the contrary, adequate fluid intake is essential to prevent dehydration and constipation, which can worsen the condition. The patient should drink at least eight glasses of water per day or more if they have a high-fiber diet.

Choice E reason:

These are not a component of treatment for diverticular disease. Enemas can irritate the colon and increase the pressure in the diverticula, which can lead to perforation or bleeding. The patient should avoid enemas unless instructed by a doctor for a specific reason.

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

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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

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.

Correct Answer is ["A","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

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