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 B

Explanation

Choice A rationale
Asking why the patient thinks the copper helps with their arthritis might seem like a good way to understand their beliefs, but it could come off as challenging or dismissive.
Choice B rationale
Acknowledging that the patient feels better wearing the bracelet is a respectful response. It validates the patient’s experience without endorsing the effectiveness of copper bracelets, which lack scientific evidence for treating arthritis.
Choice C rationale

This response could be seen as dismissive of the patient’s beliefs and experiences. It’s important to respect patients’ choices in managing their symptoms, as long as those choices aren’t harmful.
Choice D rationale
While it’s true that there’s no scientific basis for believing objects have powers to make you feel better, saying this could come off as dismissive or disrespectful.

A. Administer IV 0.9% sodium chloride injection (normal saline) B. Administer IV push (IVP) of diazepam C. Administer IV push (IVP) of gabapentin D. Administer IV 0.9% sodium chloride and 5% glucose (dextrose)

Correct Answer is D

Explanation

For a patient with hypoglycemia who has experienced a suspected seizure, the immediate intervention would be to administer IV 0.9% sodium chloride and 5% glucose (dextrose). This helps to quickly raise the patient’s blood glucose levels and manage the seizure.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

For the patient with hypoglycemia who has experienced a suspected seizure, which intervention would the nurse implement immediately?

Correct Answer is D

Explanation

A nurse is caring for a patient who has cirrhosis of the liver and is having difficulty eliminating alcohol consumption because many of their friends drink alcohol socially. Which of the following steps should the nurse include to motivate the patient to change?

A nurse is teaching a patient with hepatitis B about self-management. Which instructions should the nurse include in the teaching?

A nurse is assessing a postoperative client who has anemia due to excessive blood loss during surgery. What findings should the nurse expect?

A nurse at an outpatient surgery center is providing discharge instructions to a patient and their spouse following the surgical removal of a cataract. What should the nurse include in these instructions?

A nurse is evaluating a client who is at risk for deep-vein thrombosis (DVT). Which of the following symptoms is an indication of DVT?

A nurse is educating a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

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?

A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?