The nurse cares for a client with liver failure and monitors the client for hepatic encephalopathy. Which findings does the nurse recognize as the earliest signs of hepatic encephalopathy? Select all that apply.
A) Restlessness
B) Confusion
C) Disorientation
D) Agitation
E) Impaired judgment
A) Restlessness
D) Agitation
E) Impaired judgment
Explanation: A) Clients with hepatic encephalopathy or portal systemic encephalopathy will show neurologic changes that result from the buildup of toxins and fluid, affecting cognition. The earliest signs of encephalopathy are restlessness, agitation, and impaired judgment.
B) Confusion and disorientation are late signs of encephalopathy.
C) Confusion and disorientation are late signs of encephalopathy.
D) Clients with hepatic encephalopathy or portal systemic encephalopathy will show neurologic changes that result from the buildup of toxins and fluid, affecting cognition. The earliest signs of encephalopathy are restlessness, agitation, and impaired judgment.
E) Clients with hepatic encephalopathy or portal systemic encephalopathy will show neurologic changes that result from the buildup of toxins and fluid, affecting cognition. The earliest signs of encephalopathy are restlessness, agitation, and impaired judgment.
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