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 assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale

Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.

A. “A hiatal hernia might increase your risk for stomach cancer.”. B. “A hiatal hernia might increase your risk for GERD.”. C. “A hiatal hernia might increase your risk for lung disease.”. D. “A hiatal hernia might increase your risk for intestinal cancer.”.

Correct Answer is B

Explanation

Choice A rationale
While a hiatal hernia can cause discomfort and other symptoms, it does not directly increase the risk for stomach cancer.
Choice B rationale
A hiatal hernia might increase your risk for Gastroesophageal Reflux Disease (GERD). This is because the hernia can cause the lower esophageal sphincter to malfunction, allowing stomach acid to flow back into the esophagus, which is the main cause of GERD1.
Choice C rationale

A hiatal hernia does not directly increase the risk for lung disease. However, if the hernia is large, it could potentially cause breathing difficulties or exacerbate existing respiratory conditions.
Choice D rationale
A hiatal hernia does not increase the risk for intestinal cancer. The hernia occurs in the diaphragm, which is separate from the intestines.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse in a clinic is reviewing the laboratory values of a patient who has primary hypothyroidism. The nurse should anticipate an elevation in which of the following laboratory values?

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?

A nurse is providing discharge education to a patient who recently experienced an acute gout attack. Which patient statement indicates they have understood the treatment plan?

A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

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?

A nurse is assisting a patient with hypothyroidism in meal planning. Which foods should the nurse suggest the patient add to their diet?

A nurse is educating a patient who has long-term symptoms of GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include in the educational materials?