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: Normal serum osmolality typically ranges between 280 to 295mOsm/kg. Serum osmolality reflects the concentration of solute particles in the blood, including sodium, glucose, and blood urea nitrogen. Sodium is a major determinant of serum osmolality, but it is not the only factor. In this case, since the patient's serum sodium is within the normal range, the nurse can reasonably estimate that the serum osmolality would fall within the normal range of 280 to 295mOsm/kg. Options A, B, and D are outside the typical range for serum osmolality in a healthy individual.

Correct Answer: B

Rationale: When scoliosis progresses to a greater than 40-degree curvature, it is often treated with spinal fusion surgery. This surgical procedure involves fusing together the vertebrae in the curved part of the spine to correct the curvature. Spinal fusion surgery is typically recommended for severe cases of scoliosis to halt the progression of the curve and prevent further complications such as lung and heart problems. Other treatment options like exercise, bracing, and casting may be more suitable for milder cases or as a preventative measure in certain situations.

Correct Answer: A

Rationale: The most appropriate nursing action to control the bleeding in this situation is to apply pressure by pinching the anterior portion of the nose for five to ten minutes. This is a common first aid technique used to stop nosebleeds, known as epistaxis. Applying pressure helps promote clotting and stops the bleeding. Placing the patient in a sitting position with the neck hyperextended or packing the nostrils with gauze for several days are not recommended first-line actions for controlling a nosebleed. The use of ice compresses to the forehead and neck may constrict blood vessels but is not as effective as direct pressure to the nose in this case.

Correct Answer: B

Rationale: Further history is needed to rule out behavioral or psychological issues.