Difficulty: Medium
Average Score: 91%
Simulated
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
Correct answer
A
Rationale
Confusion and asterixis indicate hepatic encephalopathy, often precipitated by GI bleeding (A), which increases ammonia levels. Holding lactulose (B) is incorrect as it reduces ammonia. Increasing protein (C) worsens encephalopathy. Bilirubin (D) is unrelated to acute symptoms.