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 C

Explanation

Choice A reason:

This statement is not directly related to the client's use of bisacodyl tablets. It addresses irregular bowel movements in a general sense.

Choice B reason:

Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.

Choice C reason:

This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially

disrupt electrolyte levels.

Choice D reason:

While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.

A. Include foods high in fiber. B. Include foods high in starch and proteins. C. Avoid foods high in fat. D. Avoid foods high in sodium.

Correct Answer is C

Explanation

Choice A reason:

While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.

Choice B reason:

Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.

Choice C reason:

This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.

Choice D reason:

Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.

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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 caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

Correct Answer is C

Explanation

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