Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?

Reference Range:

Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]

Hold the next dose of lactulose.

Continue the prescribed dose of lactulose.

Replace total volume voided with oral or IV fluids.

Report the number of diarrhea stools to the healthcare provider (HCP).

Answer and Explanation

The Correct Answer is B

B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

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Correct Answer is C

Explanation

C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.

A. Meningococcal meningitis. B. Cerebrovascular accident (CVA). C. Intracerebral hemorrhage. D. Rocky mountain spotted fever.

Correct Answer is A

Explanation

A. Meningococcal meningitis is a bacterial infection of the meninges (the protective membranes covering the brain and spinal cord) caused by the bacterium Neisseria meningitidis. It is characterized by symptoms such as severe headache, fever, nuchal rigidity (stiff neck), and a petechial rash on the skin. The petechial rash is a distinguishing feature of meningococcal meningitis and is caused by bleeding into the skin due to disseminated intravascular coagulation (DIC) associated with the infection.
B. A cerebrovascular accident, commonly known as a stroke, occurs when blood flow to a part of the brain is interrupted, leading to tissue damage and neurological deficits. While a stroke can cause symptoms such as headache and neurological deficits, it typically does not present with fever, nuchal rigidity, or a petechial rash.

C. Intracerebral hemorrhage is bleeding within the brain tissue, often due to the rupture of a blood vessel. It can cause symptoms such as headache, neurological deficits, and alterations in consciousness, but it typically does not present with fever, nuchal rigidity, or a petechial rash.
D. Rocky mountain spotted fever (RMSF) is a bacterial infection caused by the bacterium. While RMSF can present with fever and rash, it typically does not present with nuchal rigidity, and the petechial rash associated with RMSF tends to start on the extremities rather than the arms and legs.

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Naxlex Comprehensive Predictor Exams

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Correct Answer is C

Explanation

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

Correct Answer is A

Explanation

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