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 ["3.6"]
Explanation
- To calculate the dose of Ceclor in mg, multiply the weight in kg by the dosage in mg/kg/day and divide by the number of doses per day.
- To convert pounds to kg, divide by 2.2.
- To calculate the volume of Ceclor in mL, divide the dose in mg by the concentration in mg/mL.
- Convert 66 pounds to kg: 66 / 2.2 = 30 kg
- Calculate the dose of Ceclor in mg: 30 x 45 / 3 = 450 mg
- Calculate the volume of Ceclor in mL: 450 / 125 = 3.6 mL
- The nurse would administer 3.6 mL per dose.
Correct Answer is C
Explanation
Choice A reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice B reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice C reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice D reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
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