Nokea
Which of the following actions should the nurse implement to evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy?
- A. Request that the patient stand on one foot.
- B. Ask the patient to extend both arms to the front.
- C. Instruct the patient to perform the Valsalva manoeuvre.
- D. Have the patient walk a few steps with the eyes closed.
Correct Answer: B
Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests also might be done as part of the neurological assessment but would not be diagnostic for hepatic encephalopathy.
You may also like to solve these questions
The nurse is obtaining a health history from a patient with acute pancreatitis. Which of the following information should the nurse specifically assess when conducting a health history?
- A. Alcohol use
- B. Diabetes mellitus
- C. High-protein diet
- D. Cigarette smoking
Correct Answer: A
Rationale: Alcohol use is one of the most common risk factors for pancreatitis in Canada. In Canada, the most common cause is gallbladder disease (gallstones) followed by alcoholism. Cigarette smoking, diabetes, and high-protein diets are not risk factors.
Which of the following patients should alert the nurse that screening for hepatitis C should be done?
- A. The patient eats frequent meals in fast-food restaurants.
- B. The patient recently travelled to an undeveloped country.
- C. The patient had a blood transfusion after surgery in 1999.
- D. The patient reports a one-time use of IV drugs 20 years ago.
Correct Answer: D
Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by travelling in underdeveloped countries.
The nurse is caring for a patient with severe cirrhosis who has an episode of bleeding esophageal varices. Which of the following laboratory tests should the nurse monitor to detect possible complications of the bleeding episode?
- A. Bilirubin
- B. Ammonia
- C. Potassium
- D. Prothrombin time
Correct Answer: B
Rationale: The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode.
The nurse is educating a patient with persistent pancreatitis about the prescribed pancrelipase. At which time would the nurse recommend taking the drug?
- A. Bedtime
- B. With every meal
- C. Upon arising in the morning
- D. As soon as abdominal pain starts
Correct Answer: B
Rationale: Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal or snacks.
The nurse is caring for a patient with persistent hepatitis C infection who has these
- A. Teach symptoms of variceal bleeding
- B. Review the patient's current medication list.
- C. Draw blood for hepatitis serology testing.
Correct Answer: C
Rationale: Reviewing the patient's current medication list is critical to identify drugs that may exacerbate liver damage or interact with hepatitis C treatments. Teaching about variceal bleeding is not relevant unless the patient has advanced liver disease with portal hypertension. Hepatitis serology is unnecessary since the diagnosis of persistent hepatitis C is already established.