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

Explanation

Choice A Reason:

After a Billroth I procedure, where the stomach is anastomosed directly to the duodenum, some patients may experience diarrhea and feelings of fullness due to the direct passage of food into the small intestine without the buffering effect of the pyloric valve.

Choice B reason:

Gastric reflux and belching are not typically associated with a Billroth I procedure.

Choice C reason:

Persistent feelings of hunger and thirst are not common adverse effects associated specifically with a Billroth I procedure.

Choice D reason:

Constipation or bowel incontinence are not typically associated with a Billroth I procedure, as this surgery involves the upper gastrointestinal tract.

A. Chronic gastritis B. Atelectasis C. Pneumonia D. Malignant hyperthermia E. Metabolic imbalances

Correct Answer is ["B","C","E"]

Explanation

Choice A reason:

Chronic gastritis is not a common immediate postoperative complication of gastric surgery. It is more related to long-term gastric health.

Choice B reason:

Correct. Atelectasis, or partial lung collapse, is a potential complication postoperatively, especially in abdominal surgery. The nurse should assess for signs such as decreased breath sounds and reduced oxygen saturation.

Choice C reason:

Correct. Pneumonia is a potential complication due to reduced lung function and shallow breathing after surgery. The nurse should monitor for signs like fever, increased respiratory rate, and abnormal breath sounds.

Choice D reason:

Malignant hyperthermia is a rare complication related to certain types of anesthesia agents. It is not a common complication after gastric surgery

Choice E reason:

Correct. Metabolic imbalances, such as electrolyte disturbances or changes in blood glucose levels, can occur after gastric surgery. The nurse should monitor for signs like weakness, confusion, and abnormal laboratory values.

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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 patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?

Correct Answer is A

Explanation

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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