A high ammonia level contributes to hepatic encephalopathy. As this level increases, the nursing implementation that needs to be added to the nursing care plan is:
1. mouth care.
2. seizure precautions.
3. oxygen saturation monitoring.
4. intake and output.
2
As the ammonia level rises, the patient becomes at greater risk for seizures because of the encephalopathy.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 809 and 814
OBJ: 5 TOP: Seizure Precautions
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
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