a 46 year old man with a history of cirrhosis is brought in by his wife because he has been acting strangely on examination he is disoriented is ataxi
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Nursing Elites

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Adult Medical Surgical ATI

1. A 46-year-old man with a history of cirrhosis is brought in by his wife because he has been acting strangely. On examination, he is disoriented, ataxic, and has slurred speech. He is also hyperreflexic. His white blood cell count is normal. His hematocrit is 34%. Coagulation times are elevated. His ammonia level is normal. Which of the following statements regarding his management is correct?

Correct answer: A

Rationale: This patient presents with symptoms consistent with hepatic encephalopathy. Despite having a normal ammonia level, he should be treated with lactulose and a low-protein diet as recommended for stage 2 hepatic encephalopathy. The normal ammonia level does not exclude the diagnosis, as it lacks sensitivity and specificity. Medications like lorazepam, gentamicin, and NSAIDs should be avoided due to their potential adverse effects in patients with liver disease. Acetaminophen should also be avoided in such patients.

2. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.

3. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first?

Correct answer: A

Rationale: In a patient with urinary sepsis, administering Piperacillin/tazobactam first is crucial as it is an antibiotic that directly targets the infection. Addressing the infection promptly is essential to prevent its progression and complications. Vancomycin, Pantoprazole, and Enoxaparin are important medications for the patient's overall treatment plan, but in this scenario, the antibiotic should take precedence due to the urgency of managing the sepsis.

4. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling 'out of breath' but denies any other complaints. What action should the nurse take at this time?

Correct answer: C

Rationale: In this scenario, the client is experiencing symptoms of shortness of breath, which could indicate fluid overload from the PRBC transfusion. By decreasing the intravenous flow rate of the transfusion, the nurse can slow down the rate of blood being infused, potentially alleviating the symptoms of fluid overload and shortness of breath. This intervention can help prevent further complications and promote the client's comfort and safety.

5. Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

Correct answer: A

Rationale: In a client with dysphagia and gastrointestinal symptoms such as hypoactive bowel sounds and a firm, distended abdomen, continuous tube feeding might exacerbate the symptoms. This can lead to complications and should be questioned by the nurse.

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