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The nurse is taking care of a client diagnosed with advanced liver disease with hepatic encephalopathy. Lactulose (Cephulac) is administered to the patient to reduce which of the following?

Ammonia

Muscle rigidity

Seizures

Drooling at times

Mask-like facial expression

Shuffled gait

Answer and Explanation

The Correct Answer is A

Choice A: Ammonia

Lactulose is administered to patients with hepatic encephalopathy to reduce the levels of ammonia in the blood. Hepatic encephalopathy occurs due to the liver’s inability to detoxify ammonia, a byproduct of protein metabolism. Lactulose works by converting ammonia into ammonium, which is then excreted in the stool. This helps to lower blood ammonia levels and alleviate the symptoms of hepatic encephalopathy.

Choice B: Dysarthria

Dysarthria, or difficulty in articulating words, is a common symptom of Parkinson’s disease. It results from the muscle rigidity and bradykinesia (slowness of movement) that affect the muscles involved in speech. Patients with Parkinson’s often have a soft, monotone voice and may struggle with the clarity of their speech.

Choice C: Muscle Rigidity

Muscle rigidity is one of the hallmark symptoms of Parkinson’s disease. It refers to the stiffness and inflexibility of the muscles, which can affect any part of the body. This rigidity can lead to discomfort and pain, and it contributes to the characteristic stooped posture and shuffling gait seen in Parkinson’s patients.

Choice D: Seizures

Seizures are not typically associated with Parkinson’s disease. While Parkinson’s affects the central nervous system, it primarily impacts motor function rather than causing seizure activity. Therefore, this is not a common finding in Parkinson’s patients.

Choice E: Drooling at Times

Drooling, or sialorrhea, is a common symptom in Parkinson’s disease. It occurs due to the decreased ability to swallow saliva, which can result from muscle rigidity and bradykinesia affecting the muscles involved in swallowing. This can be particularly bothersome for patients and may require management strategies.

Choice F: Mask-like Facial Expression

A mask-like facial expression, also known as hypomimia, is a common feature of Parkinson’s disease. It results from the rigidity and bradykinesia affecting the facial muscles, leading to reduced facial expressions and a fixed, staring appearance.

Choice G: Shuffled Gait

A shuffled gait is a characteristic feature of Parkinson’s disease. Patients often take small, shuffling steps and may have difficulty initiating movement. This gait pattern is due to the combination of muscle rigidity, bradykinesia, and postural instability.

Choice H: Stooped Posture

Stooped posture is another common symptom of Parkinson’s disease. It results from the muscle rigidity and postural instability that affect the patient’s ability to maintain an upright position. This can lead to a forward-leaning posture and balance issues.

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Correct Answer is ["B","C","D"]

Explanation

Choice A Reason:

Administering 0.45% NS (normal saline) at 50 mL/hr is not appropriate for a client with SIADH. This hypotonic solution can exacerbate the condition by increasing the water retention and further diluting the serum sodium levels, worsening hyponatremia. Instead, fluid restriction and hypertonic saline (such as 3% saline) are typically used to manage SIADH.

Choice B Reason:

Obtaining daily weight is crucial in managing SIADH. Daily weights help monitor fluid retention and detect any sudden changes in body weight, which can indicate worsening fluid overload or effective treatment. Accurate weight measurements are essential for assessing the client’s fluid balance and guiding treatment decisions.

Choice C Reason:

Maintaining seizure precautions is necessary for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if a seizure occurs.

Choice D Reason:

Administering 3% saline as ordered is appropriate for treating severe hyponatremia in SIADH. Hypertonic saline helps increase serum sodium levels and reduce the risk of neurological complications. It must be administered carefully and under close monitoring to avoid rapid correction of sodium levels, which can lead to osmotic demyelination syndrome.

Choice E Reason:

Encouraging fluid intake is not appropriate for clients with SIADH. Fluid restriction is a key component of managing SIADH to prevent further dilution of serum sodium levels. Encouraging fluid intake would counteract this goal and worsen the client’s condition.

A. Assessment: Patient denies vomiting B. ECG: Flattening of QRS complex angle C. ECG: Widening of the QRS complex D. Assessment: Patient consumed 60% of meal E. Assessment: Patient denies nausea F. Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication G. ECG: Shortening of P wave duration H. Assessment: Patient denies pain I. ECG: Reduction of T wave amplitude

Correct Answer is F

Explanation

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

Choice A Reason:

Assessment: Patient denies vomiting

This choice is not directly related to the effectiveness of Kayexalate. Vomiting can be a symptom of hyperkalemia, but the absence of vomiting does not indicate that the medication is working. Kayexalate works by binding potassium in the intestines and removing it through the stool, so the presence of bowel movements is a more direct indicator of its effectiveness.

Choice B Reason:

ECG: Flattening of QRS complex angle

Flattening of the QRS complex angle is not a typical ECG change associated with hyperkalemia or its treatment. Hyperkalemia typically causes widening of the QRS complex, and effective treatment would normalize this. Therefore, this choice is not correct.

Choice C Reason:

ECG: Widening of the QRS complex

Widening of the QRS complex is a sign of hyperkalemia, not its resolution. If the medication is effective, the QRS complex should return to a normal width. Therefore, this choice is not correct.

Choice D Reason:

Assessment: Patient consumed 60% of meal

While nutritional intake is important, it is not a direct indicator of the effectiveness of Kayexalate. The medication’s effectiveness is better assessed by changes in potassium levels and related symptoms, not by meal consumption.

Choice E Reason:

Assessment: Patient denies nausea

Similar to vomiting, nausea can be a symptom of hyperkalemia, but the absence of nausea does not indicate that the medication is working. The effectiveness of Kayexalate is better assessed by the presence of bowel movements and changes in potassium levels.

Choice F Reason:

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

This is the correct answer. Kayexalate works by binding potassium in the intestines and removing it through the stool. The presence of bowel movements indicates that the medication is working to remove potassium from the body. This is a direct and relevant assessment finding.

Choice G Reason:

ECG: Shortening of P wave duration

Shortening of the P wave duration is not a typical ECG change associated with hyperkalemia or its treatment. Therefore, this choice is not correct.

Choice H Reason:

Assessment: Patient denies pain

Pain is not a typical symptom of hyperkalemia, and its absence does not indicate that the medication is working. Therefore, this choice is not correct.

Choice I Reason:

ECG: Reduction of T wave amplitude

Reduction of T wave amplitude can be a sign of hypokalemia, not hyperkalemia. Effective treatment of hyperkalemia would normalize the T wave amplitude, not reduce it. Therefore, this choice is not correct.

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The nurse is taking care of a client diagnosed with advanced liver disease with hepatic encephalopathy. Lactulose (Cephulac) is administered to the patient to reduce which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

Correct Answer is F

Explanation

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