Practice Question
A nurse is caring for a client admitted to an emergency department (ED) for changes in mental status.
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Rationale:
🧠 Hepatic Encephalopathy
🔷 Definition & Cause: Hepatic encephalopathy is a neurologic disorder resulting from liver dysfunction, where the liver fails to detoxify ammonia and other toxins, allowing them to accumulate in the bloodstream and affect brain function.
🔷 Underlying Mechanism: The impaired metabolism of ammonia leads to toxic effects on the central nervous system (CNS), altering neurotransmission and resulting in mental status changes, confusion, or lethargy.
🔷 Risk Factors: The client’s history of chronic liver failure and alcoholism significantly increases susceptibility, as both conditions damage liver cells and impair detoxification pathways.
🔷 Clinical Manifestations: Common signs include lethargy, irritability, confusion, disorientation, asterixis (flapping hand tremors), and slowed thought processes. In severe stages, clients may progress to stupor or coma.
🔷 Treatment Connection: The administration of lactulose confirms the diagnosis and management goal—this medication reduces serum ammonia levels by promoting its excretion through the stool.
⚡ Neurologic Assessment as Evidence
💠 Cognitive Findings: The client’s lethargy and disorientation are hallmark neurologic indicators of hepatic encephalopathy, showing that ammonia accumulation is affecting brain activity.
💠 Motor Findings: The presence of hand tremors (asterixis) reflects a loss of fine motor control associated with elevated neurotoxins. This is a defining clinical sign of neurologic impairment from liver dysfunction.
💠 EEG Support: The electroencephalography (EEG) revealing generalized slowing supports a diagnosis of cerebral dysfunction, which aligns with hepatic encephalopathy rather than isolated liver disease.
💠 Clinical Priority: Continuous neurologic monitoring is essential, as worsening symptoms may indicate rising ammonia levels and progression toward coma.
💠 Nursing Implications: Nurses should frequently assess level of consciousness, orientation, and motor coordination, monitor ammonia levels, and ensure compliance with lactulose therapy.
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This question is from RN Concept Based Level Assessment 4 which contains 140 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Concept-Based Assessment Level Exam(s)
- Answer Choices: 0