NCLEX PN Practice Tests Practice Question
During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.
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