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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Step 1: Calculate the total infusion time in minutes.
8 hours × 60 minutes/hour = 480 minutes
Result at each step = 480 minutes
Step 2: Calculate the total number of drops to be infused.
1,000 mL × 15 drops/mL = 15,000 drops
Result at each step = 15,000 drops
Step 3: Calculate the infusion rate in drops per minute.
15,000 drops ÷ 480 minutes = 31.25 drops/minute
Result at each step = 31.25 drops/minute
Step 4: Round to the nearest whole number if necessary.
31.25 drops/minute rounds to 31 drops/minute
Result at each step = 31 drops/minute
Therefore, the nurse should run the IV infusion at a rate of 31 drops per minute.
Correct Answer is A
Explanation
Choice A Reason:
Place the client on aspiration precautions: Myxedema coma is a severe form of hypothyroidism that can lead to decreased mental function and a reduced level of consciousness. These conditions increase the risk of aspiration, which can lead to pneumonia and other complications. Therefore, placing the client on aspiration precautions is crucial to prevent these risks. Aspiration precautions may include elevating the head of the bed, monitoring swallowing ability, and providing thickened liquids if necessary.
Choice B Reason:
Turn the client every 4 hours: While turning the client regularly is important to prevent pressure ulcers, it is not the primary action needed for a client in a myxedema coma. The focus should be on stabilizing the client’s condition and preventing life-threatening complications such as aspiration, respiratory failure, and cardiovascular collapse.
Choice C Reason:
Check the client’s blood pressure every 2 hours: Monitoring vital signs, including blood pressure, is essential for clients in a myxedema coma. However, it is not the most critical action compared to preventing aspiration. Blood pressure should be monitored regularly, but the frequency can be adjusted based on the client’s condition and stability.
Choice D Reason:
Initiate measures to cool the client: Clients in a myxedema coma typically present with hypothermia (low body temperature), not hyperthermia (high body temperature). Therefore, initiating measures to cool the client would be inappropriate and could worsen their condition. Instead, measures to warm the client, such as using blankets and adjusting room temperature, are more appropriate.
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