A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for:
A. Malaise
B. Stomatitis
C. Hand tremors
D. Weight loss
Correct Answer: C. Hand tremors
Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. During the intermediate stages of HE, a characteristic jerking movement of the limbs is often observed (e.g., asterixis) when the patient attempts to hold arms outstretched with hands bent upward at the wrist.
Option A: Malaise is not related to neurological involvement. Other physical signs may include hyperreflexia, a positive Babinski’s sign, or Parkinsonian symptoms (e.g., rigidity or tremors). Symptoms typically include confusion, personality changes, disorientation, and a depressed level of consciousness. The earliest stage is often characterized by an inverted sleep-wake pattern wherein patients are found to be sleeping during the day and awake throughout the night.
Option B: Stomatitis is not related to neurological involvement. Throughout the intermediate stages, patients tend to experience worsening levels of confusion, lethargy, and personality changes. In the advanced stages, hepatic encephalopathy may eventually lead to coma (e.g., hepatic coma or coma hepaticum) and ultimately to death.
Option D: These clients typically have ascites and edema so experience weight gain. In order to make a diagnosis of HE, there must be confirmed the presence of liver disease (e.g., abnormal liver function tests, ultrasound or liver biopsy demonstrating liver disease) or a portosystemic shunt, and exclusion of other potential etiologies (e.g., intracranial lesions, masses, hemorrhage or stroke; seizure activity; post-seizure encephalopathy; intracranial infections; or toxic encephalopathy from other causes).
No comments:
Post a Comment