Question
A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
Stage 1 Stage 3 Stage 2 Stage 4
Stage 1 Stage 3 Stage 2 Stage 4
Answers
GPT-4o mini
Based on the clinical findings you’ve described—episodes of confusion, difficulty arousing from sleep, and rigid extremities—the nurse should document this as **Stage 3** of hepatic encephalopathy.
In hepatic encephalopathy, the stages are generally classified as follows:
- **Stage 1:** Mild confusion, easy to arouse, asterixis (flapping tremor).
- **Stage 2:** Increased confusion, lethargy, and noticeable asterixis, but the patient can still be aroused.
- **Stage 3:** Severe confusion, somnolence, difficulty arousing, and rigidity may be present.
- **Stage 4:** Coma, unresponsiveness.
The presence of confusion combined with difficulty in arousal and rigidity points to Stage 3.
In hepatic encephalopathy, the stages are generally classified as follows:
- **Stage 1:** Mild confusion, easy to arouse, asterixis (flapping tremor).
- **Stage 2:** Increased confusion, lethargy, and noticeable asterixis, but the patient can still be aroused.
- **Stage 3:** Severe confusion, somnolence, difficulty arousing, and rigidity may be present.
- **Stage 4:** Coma, unresponsiveness.
The presence of confusion combined with difficulty in arousal and rigidity points to Stage 3.