A patient with acute hepatic dysfunction is having difficulty completing his menu and "can't seem to remember" how to use the bed controls
The nurse realizes these changes might indicate which of the following stages of hepatic encephalopathy? 1. I
2. II
3. III
4. IV
1
Rationale: Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes. Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place. In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing. Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.
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A client, age 60, has obtained physician approval to begin a light exercise program that will include walking and swimming. The client questions the nurse about his ability to actually have success in physical training
What response by the nurse is indicated? A) "There may be a reduction in ability to train as a result of a lack of muscle regeneration." B) "Muscle tissue is still able to be trained effectively." C) "There will be some age-related changes, as you have lost half of your muscle mass." D) "Muscle fibers atrophy, preventing training."
The instructor of the physiology class for prenursing students is talking about the lower respiratory tract. The instructor talks about the visceral and parietal pleura and the small amount of fluid between the two membranes
What does the instructor tell her students the function of the pleura and the pleural fluid is? A) Allows for full expansion of the lungs within the thoracic cavity B) Prevents the lungs from collapsing within the thoracic cavity C) Determines lung expansion within the thoracic cavity D) Permits smooth motion of the lungs within the thoracic cavity
A client with a head injury has had the caloric test performed using ice-cold water. When the water was injected into the auditory canal, the client's eyes moved slowly toward the irrigated side and then quickly returned to midline
The nurse would conclude after watching this reaction that the client a. has an intact brain stem. b. has brain death. c. is likely to arouse within 24 hours. d. will be permanently deaf.
A patient in the second stage of labor is becoming increasingly fatigued. Which interventions should the nurse use to help the patient rest? (Select all that apply.)
A) Provide a sedative B) Support the patient with pillows C) Apply a cool cloth to the forehead D) Provide a back rub between contractions E) Assist the patient into a comfortable position