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 A
Explanation
Choice A reason:
IV hydromorphone is an opioid analgesic that can provide effective pain relief and can be titrated to the patient's needs. It's commonly used for severe pain associated with conditions like acute pancreatitis.
Choice B reason:
Oral naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that may be used for pain relief, but it's not the first-line treatment for acute pancreatitis. NSAIDs can potentially worsen the condition due to their effects on the gastrointestinal tract.
Choice C reason:
IM meperidine is an opioid analgesic that can be used for pain relief. However, in severe cases of acute pancreatitis, IV opioids are often preferred for more immediate and precise pain control.
Choice D reason:
Oral oxycodone is another opioid analgesic. However, in cases of acute pancreatitis, especially when pain is severe, IV opioids are often the preferred route of administration for more rapid and reliable pain relief.
Correct Answer is C
Explanation
Choice A reason:
This statement does not address the client's use of bisacodyl tablets and instead provides general information about irregular bowel movements.
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.
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