A nurse is caring for an older adult patient who has just been admitted to the intensive care unit with a diagnosis of confusion/delirium.The patient has an end-stage liver failure diagnosis with increasing ascites.
Their spouse Questions the nurse about the patient’s mental status because they state that the patient is usually lucid. Which of the following is likely the contributing factor for the admitting diagnosis?

This is likely related to new-onset dementia.

This is likely related to new-onset schizophrenia.

This is likely related to new-onset hepatic encephalopathy.

This is likely related to a new-onset UTI.

Answer and Explanation

The Correct Answer is C

Choice C rationale
Hepatic encephalopathy is a condition that can cause confusion or delirium in patients with end-stage liver disease and increasing ascites. It occurs when the liver is unable to remove toxins from the blood, such as ammonia, which can then accumulate in the brain and affect mental function. This condition is common in patients with cirrhosis or end-stage liver disease, and can manifest as confusion, changes in sleep patterns, mood alterations, and, in severe cases, coma.
Choice A rationale
While dementia can cause confusion and changes in mental status, it is typically a progressive condition that develops over time. In the context of a patient with end-stage liver failure and

increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice B rationale
Schizophrenia is a chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It is not typically associated with end-stage liver disease or ascites. In the context of a patient with end-stage liver failure and increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice D rationale
While a urinary tract infection (UTI) can cause confusion, especially in older adults, it would not typically be the primary suspect in a patient with end-stage liver failure and increasing ascites. In such a patient, hepatic encephalopathy is a more likely cause of confusion or delirium.

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Correct Answer is D

Explanation

Choice A rationale
While it is true that an increased weight in the abdomen can lead to discomfort when lying down, simply having extra pillows in bed may not be sufficient to address the issue. Ascites, or the accumulation of fluid in the peritoneal cavity, can cause significant discomfort and even

pain. It can also lead to respiratory issues as the fluid puts pressure on the diaphragm, making breathing difficult. Therefore, while extra pillows may help to some extent by allowing the patient to find a more comfortable position, they are not a comprehensive solution.
Choice B rationale
Advising the patient not to wear undergarments because they will not fit due to the increased weight in the abdomen is not a medically sound advice. While it is true that ascites can cause distension of the abdomen, the focus should be on treating the underlying condition and managing the symptoms, rather than on the fit of the patient’s clothing. Moreover, the choice of clothing is a personal decision and may have psychological implications for the patient.
Choice C rationale
The statement that the increased weight in the abdomen means that the patient can no longer exercise due to the strain on the heart is not entirely accurate. While it is true that ascites can put additional strain on the heart and other organs, it does not necessarily mean that all forms of exercise are contraindicated. In fact, gentle forms of exercise may be beneficial for overall health and well-being. However, any exercise regimen should be discussed with and approved by a healthcare provider.
Choice D rationale
This is the correct choice. Due to the increased abdominal weight from ascites, the patient’s balance might indeed be affected, increasing the risk of falls. Therefore, advising the patient to take their time with walking is a valid precaution. Fall prevention is a key aspect of care for patients with ascites due to end-stage liver disease.

A. Avoid serving raw foods. B. Wear barrier protection during vaginal intercourse. C. Avoid eating at fast food restaurants. D. Practice effective hand hygiene.

Correct Answer is ["A","D"]

Explanation

Choice A rationale
Hepatitis A is a highly contagious virus that spreads through person-to-person contact or consuming contaminated food or drink. The virus can contaminate food during growing, harvesting, processing, handling, and even after cooking. Therefore, avoiding serving raw foods can help prevent the spread of the virus.
Choice B rationale

Hepatitis A is not typically spread through sexual intercourse. It is primarily spread through the fecal-oral route, either by person-to-person contact or consumption of contaminated food or water. Therefore, wearing barrier protection during vaginal intercourse is not a primary prevention strategy for Hepatitis A.
Choice C rationale
While it’s possible to contract Hepatitis A from food prepared at any location, including fast food restaurants, the risk is not specifically associated with these establishments. The key is whether the food is contaminated with the virus, which can occur in any setting if food is handled by someone infected with Hepatitis A who doesn’t properly wash their hands after using the toilet.
Choice D rationale
Practicing effective hand hygiene, including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food, is a primary prevention strategy for Hepatitis A1. The virus is spread in part by the fecal-oral route, so good hand hygiene can help prevent ingestion of the virus.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an elderly patient with significant ascites due to end-stage liver disease. Which of the following precautions should the nurse include in the patient’s care plan?

Correct Answer is D

Explanation

A nurse is educating a client who has hepatitis A on how to prevent the spread of the virus. Which of the following strategies should the nurse include in the teaching?

Correct Answer is ["A","D"]

Explanation

A nurse is transferring a patient to the surgical unit postoperatively. During the handoff report, the nurse states that “Dr. Jones performed a bowel resection.”. Which section of the SBAR Communication tool does this statement address?

The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

A nurse is caring for a patient newly diagnosed with hepatitis. Which nurse response best explains how a person can contract the virus?

A nurse is educating a client who has recently been diagnosed with gastroesophageal reflux disease (GERD). The client inquires about foods to avoid. Which food should the nurse advise the client to avoid?

A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following information should the nurse include in the teaching?

The nurse is caring for a patient with active hepatitis C and recalls that the disease is spread by which route?

Which of the following assessments would be most useful in determining a patient’s genetic risk for breast cancer?

A nurse is caring for a patient in the primary care office who has a recent diagnosis of a hiatal hernia. Which of the following new information will be beneficial for the nurse to relay to the patient?