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
Nonfat milk is generally not a trigger for GERD101112131415. It is low in fat and thus less likely to relax the lower esophageal sphincter, which can lead to acid reflux1415.
Choice B rationale

Chocolate is known to trigger GERD symptoms1415. It contains caffeine and fat, which can relax the lower esophageal sphincter and cause acid reflux1415.
Choice C rationale
Oatmeal is generally not a trigger for GERD101112131415. It is a whole grain that is high in fiber, which can help control GERD symptoms1415.
Choice D rationale
Apples are generally not a trigger for GERD101112131415. They are non-citrus fruits and thus less likely to cause acid reflux1415.

A. Implementing a bleeding precaution protocol B. Implementing a skin safety protocol C. Implementing a sodium restriction diet D. Implementing a fall risk protocol

Correct Answer is D

Explanation

Choice A rationale
While bleeding precautions are important in certain conditions, they may not be the priority for a patient with significant abdominal ascites. Ascites, the accumulation of fluid in the peritoneal cavity, is often caused by liver disease such as cirrhosis.
Choice B rationale
Skin safety protocols are important for all patients, but they may not be the priority in this case. Ascites can cause discomfort and other complications, but it does not directly cause skin problems.
Choice C rationale
A sodium restriction diet can be beneficial for patients with ascites, as it can help reduce fluid accumulation. However, this measure may not be the priority in this case.
Choice D rationale
Implementing a fall risk protocol should be prioritized. The patient’s significant abdominal ascites could affect their balance and mobility, increasing their risk of falls. Furthermore, the patient usually uses a cane for support but forgot to bring it to the hospital, further increasing their fall risk.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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?

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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?

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