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:

Abdominal bloating and flank pain may be associated with various gastrointestinal conditions, but they are not the most common signs of possible colon cancer.

Choice B reason:

This statement is correct. A change in bowel habits, such as persistent constipation, diarrhea, or a change in stool consistency, is the most common sign of possible colon cancer.

Choice C reason:

Unexplained weight gain is not typically associated with colon cancer; unexplained weight loss may be more indicative.

Choice D reason:

The development of new hemorrhoids is not a common sign of possible colon cancer.

A. Level of consciousness B. Gag reflex C. Nausea D. Pain

Correct Answer is B

Explanation

Choice A reason:

While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.

Choice B reason:

This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.

Choice C reason:

Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.

Choice D reason:

Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.

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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 nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?

Correct Answer is B

Explanation

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

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