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 C
Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.
Choice C reason:
This statement is correct. Confirming placement of the tube prior to each medication
administration is crucial to ensure safe and effective delivery of medications and nutrition.
Choice D reason:
Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.
Correct Answer is D
Explanation
Choice A reason:
Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.
Choice B reason:
Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.
Choice C reason:
While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube
maintenance.
Choice D reason:
Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the
tube correctly.
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