Question

Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.)

A. Assessing the client's neurologic status every 2 hours
B. Monitoring the client's hemoglobin and hematocrit levels
C. Evaluating the client's serum ammonia level
D. Monitoring the client's handwriting daily
E. Preparing to insert an esophageal tamponade tube
F. Making sure the client's fingernails are short

Answer 1

To manage hepatic encephalopathy in a patient with end-stage liver failure, a nurse should assess the client's neurologic status regularly, monitor serum ammonia levels, and observe daily changes in handwriting for signs of impaired neurological function.

Step-by-step explanation:

When addressing hepatic encephalopathy in a patient with end-stage liver failure, several nursing interventions are crucial. These interventions should include:

• Assessing the client's neurologic status every 2 hours to monitor for changes in consciousness and behavior, which can indicate worsening encephalopathy.
• Evaluating the client's serum ammonia level, as elevated ammonia levels are associated with hepatic encephalopathy and need careful monitoring and management.
• Monitoring the client's handwriting daily as a non-invasive method to assess for subtle changes in motor skills, which can also reflect alterations in neurological function.

Monitoring hemoglobin and hematocrit levels may be necessary for overall patient care, but these tests are not directly tied to the management of hepatic encephalopathy. Preparing to insert an esophageal tamponade tube is specific to complications such as variceal bleeding and not directly related to hepatic encephalopathy. Ensuring the client's fingernails are short is good practice for preventing self-harm if the patient has compromised mental status, but it is not specific to the management of encephalopathy.