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A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: C
Rationale: The correct answer is C: Stage 3. In hepatic encephalopathy, Stage 3 is characterized by severe confusion, difficulty arousing from sleep, and potential development of rigid extremities due to worsening brain function. This stage indicates significant impairment and requires immediate medical attention. Stage 1 and 2 are milder forms with less severe symptoms, while Stage 4 represents coma and severe neurological dysfunction, which is beyond the presented symptoms. Therefore, based on the client's clinical findings of confusion, difficulty arousing from sleep, and rigid extremities, Stage 3 is the most appropriate stage to document.
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A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
- A. Two to three soft bowel movements daily
- B. Significant increase in appetite and food intake
- C. Absence of nausea and vomiting
- D. Absence of blood or mucus in stool
Correct Answer: A
Rationale: The correct answer is A: Two to three soft bowel movements daily. Lactulose is a laxative commonly used to manage hepatic encephalopathy by reducing ammonia levels through promoting bowel movements. The desired outcome of this medication is to prevent the buildup of ammonia in the bloodstream, which can exacerbate hepatic encephalopathy. Soft bowel movements indicate that the medication is effectively promoting bowel motility and reducing ammonia levels. Choices B, C, and D are incorrect as lactulose is not directly associated with increasing appetite, resolving nausea and vomiting, or eliminating blood or mucus in the stool in this context.
A client with a history of chronic alcohol abuse is at risk for which of the following conditions?
- A. Liver cirrhosis
- B. Renal failure
- C. Chronic obstructive pulmonary disease (COPD)
- D. Peptic ulcer disease
Correct Answer: A
Rationale: The correct answer is A: Liver cirrhosis. Chronic alcohol abuse is a leading cause of liver cirrhosis due to the toxic effects of alcohol on the liver over time. Alcohol metabolism leads to liver inflammation, scarring, and ultimately cirrhosis. Renal failure (B) is not directly linked to alcohol abuse but can occur in severe cases. COPD (C) is primarily caused by smoking, not alcohol abuse. Peptic ulcer disease (D) can be exacerbated by alcohol but is not directly caused by chronic alcohol abuse. Therefore, the most significant risk for a client with a history of chronic alcohol abuse is developing liver cirrhosis.
A patient is being cared for after bariatric surgery, and the healthcare provider is assessing for hemorrhage. What is a sign of hemorrhage?
- A. Increase in blood pressure
- B. Frank red bleeding from the surgical site
- C. Clear drainage from the surgical wound
- D. Decrease in heart rate
Correct Answer: B
Rationale: The correct answer is B: Frank red bleeding from the surgical site. This is indicative of hemorrhage post-bariatric surgery as it signifies active bleeding. Clear drainage (Choice C) is normal post-surgery. An increase in blood pressure (Choice A) could be a sign of shock from hemorrhage, but it's not specific. A decrease in heart rate (Choice D) is not typically a sign of hemorrhage.
The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
- A. Warm skin, hypertension, and constricted pupils.
- B. Bradycardia, hypotension, and respiratory acidosis.
- C. Mottled skin, tachypnea, and hyperactive bowel sounds.
- D. Tachycardia, mental status change, and low urine output.
Correct Answer: D
Rationale: The correct answer is D: Tachycardia, mental status change, and low urine output. In the early stages of shock, the body compensates by increasing heart rate (tachycardia) to maintain perfusion. Mental status change can indicate decreased cerebral perfusion. Low urine output is a sign of decreased renal perfusion.
A: Warm skin, hypertension, and constricted pupils are not indicative of shock. In shock, skin becomes cool and clammy, blood pressure drops, and pupils dilate.
B: Bradycardia, hypotension, and respiratory acidosis are not early signs of shock. Bradycardia and hypotension occur in the late stages of shock. Respiratory acidosis is a complication of shock, not an early symptom.
C: Mottled skin, tachypnea, and hyperactive bowel sounds are signs of shock but not early indicators. Mottled skin appears in the late stages of shock, tach
The healthcare provider is providing care to a client with a tracheostomy. Which action should the healthcare provider take to prevent tracheostomy complications?
- A. Use sterile technique when performing tracheostomy care.
- B. Suction the tracheostomy tube every hour.
- C. Keep the tracheostomy tube cuff inflated at all times.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: The correct answer is A: Use sterile technique when performing tracheostomy care. This is crucial to prevent infections that can lead to complications. Sterile technique helps minimize the risk of introducing harmful pathogens into the tracheostomy site. Using clean rather than sterile technique can increase the client's risk of infection.
Choice B is incorrect because suctioning the tracheostomy tube every hour can lead to mucosal damage and increase the risk of infection. Choice C is incorrect because keeping the tracheostomy tube cuff inflated at all times can cause pressure ulcers and damage the trachea. Choice D is incorrect because changing the tracheostomy ties daily is unnecessary and can increase the risk of dislodging the tracheostomy tube, leading to complications.