Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?

Correct Answer: C

Rationale: Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, such as cirrhosis, where the liver's ability to metabolize ammonia is impaired. As a result, there is an increase in serum ammonia levels, leading to alterations in brain function and neurotransmission. Symptoms such as confusion, restlessness, and asterixis (flapping tremor) are characteristic of hepatic encephalopathy caused by increased ammonia levels affecting the brain. Therefore, altered thought processes in Mrs. Silang are primarily related to the increased serum ammonia levels rather than other factors like massive ascites formation, fluid volume excess, or altered clotting mechanism.

Correct Answer: C

Rationale: Pyridoxine, also known as vitamin B6, is necessary for the prevention of INH-induced peripheral neuropathy. INH can lead to a deficiency of vitamin B6 in the body, which in turn can cause nerve damage and peripheral neuropathy. By supplementing the diet with pyridoxine, the risk of developing peripheral neuropathy as a side effect of INH administration can be minimized. It is an important preventive measure recommended for those undergoing treatment with INH to ensure the proper functioning of the nervous system and prevent nerve damage.

Correct Answer: D

Rationale: The primary complication of osteoporosis is fractures. Osteoporosis is a condition characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility and susceptibility to fractures. Fractures, especially in the spine, hip, and wrist, are common complications of osteoporosis and can significantly impact an individual's quality of life. Patients with osteoporosis are at an increased risk of fractures from minor trauma or even during normal daily activities. Therefore, preventing fractures is a key focus in the management of osteoporosis to minimize pain, disability, and complications associated with bone fractures.

Correct Answer: A

Rationale: Administering morphine sulfate as ordered would be an appropriate nursing intervention for Aling Loida who is complaining of acute abdominal pain. Morphine is a potent analgesic that can help alleviate severe pain. Pain management is crucial in acute pancreatitis to help the patient feel more comfortable and to improve their overall well-being. It is important to follow the healthcare provider's orders regarding the administration of pain medication to ensure effective pain relief for the patient.

Correct Answer: D

Rationale: When mixing two types of insulin in one syringe, it is important to draw up the clear insulin first before drawing up the cloudy insulin. This is done to prevent contamination and ensure accurate dosing. Drawing up the clear insulin first helps to prevent the cloudy insulin from contaminating the clear insulin and maintains the proper ratio of each insulin type. It is an important technique to ensure the effectiveness and safety of insulin administration for the client.