Reflecting upon the client's other symptoms, the nurse determines the client likely has developed hepatic encephalopathy when the client:
1. Becomes increasingly agitated, with changes in mentation.
2. Begins to have bleeding esophageal varices.
3. Has ascites.
4. Begins to complain of a significant headache.
Becomes increasingly agitated with changes in mentation.
Rationale: Clients will exhibit symptoms of changing mentation with possible agitation as they develop hepatic encephalopathy. Bleeding esophageal varices and ascites only indicate the client has hepatic portal hypertension. Developing a headache is not indicative of hepatic encephalopathy.
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