Rohan, a patient with cirrhosis, is being evaluated in the hospital for possible hepatic complications. Which of the following findings would most likely indicate that Rohan is developing hepatic encephalopathy?

• Increased prothrombin time and elevated bilirubin levels

• Asterixis and altered level of consciousness

• Ascites and peripheral edema

• Elevated serum albumin and decreased ammonia levels

Answer explanation

Asterixis and altered level of consciousness are classic signs of hepatic encephalopathy, indicating impaired brain function due to liver failure. Other options relate to liver dysfunction but do not specifically indicate encephalopathy.

Daniel, a patient diagnosed with acute cholecystitis, is scheduled for surgery. As his nurse, which of the following preoperative assessments is most critical for you to perform?

• Assessing the patient's pain level

• Evaluating the patient's nutritional status

• Monitoring for signs of infection

• Checking for the presence of jaundice

Answer explanation

Monitoring for signs of infection is critical in acute cholecystitis as it can indicate complications like perforation or sepsis, which can affect surgical outcomes. Early detection allows for timely intervention.

Kai, a patient with hepatic encephalopathy, is receiving lactulose as part of his treatment. The nurse caring for Kai observes that he is having more frequent bowel movements than before. What is the most appropriate nursing action?

• Administer an antidiarrheal medication

• Document the findings and continue monitoring

• Notify the healthcare provider of the increased frequency

• Decrease the dosage of lactulose

Answer explanation

Increased bowel movements are a common effect of lactulose, which helps reduce ammonia levels. The appropriate action is to document the findings and continue monitoring, as this may not indicate a need for intervention.

Emma has recently been hospitalized for pancreatitis and is now being discharged. During her discharge instructions, she discusses how she will manage her condition at home. Which statement by Emma indicates a need for further education?

• I will avoid alcohol completely.

• I can eat a high-protein diet to help with healing.

• I should monitor my blood sugar levels regularly.

• I can resume my normal diet as soon as I feel better.

Answer explanation

The statement "I can resume my normal diet as soon as I feel better" indicates a need for further education. Patients with pancreatitis should follow a specific diet plan and not return to normal eating immediately.

Lily, a patient with a history of liver cirrhosis, is admitted to the hospital. The healthcare team is concerned about the possibility of her developing spontaneous bacterial peritonitis (SBP). Which of the following assessments would be most indicative of this complication?

• Increased abdominal girth and fever

• Decreased urine output and jaundice

• Elevated blood pressure and tachycardia

• Hypoactive bowel sounds and weight loss

Answer explanation

Increased abdominal girth and fever are classic signs of spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis, indicating fluid accumulation and infection.

Mia, a nurse, is preparing to administer pancrelipase to a patient diagnosed with pancreatitis. Before giving the medication, which of the following assessments should Mia prioritize?

• Assessing the patient's pain level

• Evaluating the patient's nutritional intake

• Monitoring the patient's respiratory status

• Checking the patient's stool consistency

Answer explanation

Checking the patient's stool consistency is crucial before administering pancrelipase, as it indicates the effectiveness of enzyme replacement therapy in managing malabsorption due to pancreatitis.

Jackson, who has been diagnosed with cirrhosis, is meeting with his nurse to discuss dietary restrictions. Which of the following dietary choices should the nurse advise Jackson to limit? Select all that apply

• Fresh fruits and vegetables

• Whole grains and legumes

• High-protein foods

• Processed foods and high-sodium snacks

Answer explanation

Patients with cirrhosis should limit high-protein foods to prevent hepatic encephalopathy and reduce ammonia levels. Processed foods and high-sodium snacks should also be limited to manage fluid retention and hypertension.

During a follow-up appointment, Sophia, who has hepatic encephalopathy, is discussing her treatment plan with her nurse. The nurse emphasizes the importance of medication adherence. Which statement by Sophia indicates a correct understanding of her condition?

• I can stop taking my medications if I feel better.

• I need to monitor my symptoms and report any changes.

• I should increase my protein intake to help my liver.

• I can take over-the-counter medications without consulting my doctor.

Answer explanation

The correct statement indicates understanding that monitoring symptoms is crucial in hepatic encephalopathy. This condition can fluctuate, and reporting changes helps manage treatment effectively.

Kai, a nurse, is caring for a patient who has just experienced a stroke in the emergency department. Which of the following assessments should Kai prioritize to determine the patient's immediate needs?

• Assessing the patient's ability to speak

• Checking the patient's blood pressure

• Evaluating the patient's level of consciousness

• Performing a neurological assessment using the NIH Stroke Scale

Answer explanation

Evaluating the patient's level of consciousness is crucial after a stroke, as it helps assess the severity of the stroke and immediate needs for intervention, guiding further assessments and treatments.

David, a patient with a spinal cord injury, suddenly develops a pounding headache, flushed skin above the level of injury, and high blood pressure while in the hospital. The nurse suspects autonomic dysreflexia. Which nursing intervention should be implemented first?

• Administer antihypertensive medication

• Lay the patient flat

• Assess for and relieve the cause of the dysreflexia

• Monitor vital signs every 15 minutes

Answer explanation

In autonomic dysreflexia, the priority is to identify and relieve the triggering cause, such as a full bladder or skin irritation, to prevent complications. Administering medication or monitoring vital signs comes after addressing the cause.

Tags

NGSS.HS-LS1-3