A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase?
a. Mouth care
b. Increased frequency of neurologic checks
c. Oxygen saturation monitoring
d. Intake and output
B
As the ammonia level rises, the patient becomes at greater risk for confusion and hepatic coma related to encephalopathy.
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A nurse wishes to assess how often members of a family consume alcohol or use drugs during a typical week. What type of family assessment tool would this nurse choose?
A. Ecomap B. Genogram C. Qualitative D. Quantitative
A nurse is caring for a patient experiencing respiratory distress. The physician places an endotracheal tube. The most appropriate nursing diagnosis for this patient is:
a. ineffective coping. b. risk for infection. c. altered nutrition: less than body requirements. d. impaired verbal communication.
Which of the following is not part of the five steps in the NCSBN decision-making tree used for delegation?
a. assessment, planning, and communication b. intervention and supervision c. surveillance and supervision d. evaluation and feedback
A nurse is caring for a person who is delusional. What is important for the nurse to do while communicating with the patient?
A) Touch the patient gently while talking. B) Avoid arguing about erroneous statements. C) Reinforce reality for delusional statements. D) Maintain eye contact at all times.