The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

Bradycardia

Asterixis

Fever

Melena

Answer and Explanation

The Correct Answer is B

A) Bradycardia is not typically associated with hepatic encephalopathy.

B) Asterixis is a characteristic finding in hepatic encephalopathy, known as "flapping tremor," indicating neuromuscular irritability due to elevated blood ammonia levels.
C) Fever is not a common direct symptom of hepatic encephalopathy.

D) Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.

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Correct Answer is D

Explanation

A) Requesting a dietary consult is useful but not the most immediate action needed.

B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

A. Auscultate lungs B. Monitor I&O C. Check stools for blood D. Initiate fall precautions

Correct Answer is C

Explanation

A) While important, it is not directly related to the coagulopathy indicated by the prolonged PT.
B) Important for overall fluid management but not directly related to the risk of bleeding.
C) With a significantly prolonged PT, assessing for signs of gastrointestinal bleeding is a priority.

D) Important for safety, but the immediate risk of bleeding due to coagulopathy takes precedence.

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The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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