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:

Gallstones are a common cause of acute pancreatitis, as they can obstruct the pancreatic duct and lead to inflammation.

Choice B reason:

While diabetes mellitus can be a risk factor for pancreatitis, it is not specific to acute pancreatitis.

Choice C reason:

Chronic obstructive pulmonary disease (COPD) is not directly related to acute pancreatitis.

Choice D reason:

Hypolipidemia (low blood lipid levels) is not a common risk factor for acute pancreatitis.

A. Severe diarrhea B. Involvement of the rectal mucosa C. An absence of blood in stool D. A pattern of distinct exacerbations and remissions

Correct Answer is D

Explanation

Choice A reason:

Severe diarrhea can be a symptom of both Crohn's disease and ulcerative colitis and does not specifically indicate one over the other.

Choice B reason:

Involvement of the rectal mucosa is more indicative of ulcerative colitis rather than Crohn's disease, as Crohn's disease can affect any part of the digestive tract.

Choice C reason:

The presence or absence of blood in stool is not a definitive indicator of either Crohn's disease or ulcerative colitis, as both conditions can involve bleeding.

Choice D reason:

This statement is correct. A pattern of distinct exacerbations and remissions is more characteristic of Crohn's disease, whereas ulcerative colitis often presents with continuous, chronic symptoms.

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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 interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Correct Answer is A

Explanation

A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the patient's signs and symptoms?

Correct Answer is D

Explanation

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?

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

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