# During morning rounds, a nurse observes that a 65-year-old client with a history of alcoholic liver disease has become increasingly lethargic, is disoriented to place, and demonstrates a flapping tremor when arms are extended. To manage the underlying physiological cause of this clinical deterioration, which priority action should the nurse take? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540548 > language: ko > subject: Adult Health ## 문제 During morning rounds, a nurse observes that a 65-year-old client with a history of alcoholic liver disease has become increasingly lethargic, is disoriented to place, and demonstrates a flapping tremor when arms are extended. To manage the underlying physiological cause of this clinical deterioration, which priority action should the nurse take? ## 보기 1. Monitor neurological status and implement safety measures 2. Administer prescribed lactulose as ordered **✔ 정답** 3. Restrict dietary protein intake 4. Prepare for potential paracentesis procedure **정답: 2** ## 해설 Lactulose is the priority as it directly reduces ammonia, the underlying cause of hepatic encephalopathy. Other options address symptoms (monitoring), long-term management (protein restriction), or complications (paracentesis) but do not treat the immediate cause. ## 심화 해설 Clinical Presentation and Pathophysiology The client’s history of alcoholic liver disease, progressive lethargy, disorientation, and the presence of a flapping tremor (asterixis) strongly suggest a diagnosis of overt hepatic encephalopathy (HE). HE is a neuropsychiatric complication of advanced liver disease and cirrhosis, resulting from the liver’s inability to clear gut-derived neurotoxins, primarily ammonia, from the portal circulation. Hyperammonemia is widely regarded as the central hallmark of HE pathogenesis, as ammonia crosses the blood-brain barrier and causes astrocyte swelling and cerebral dysfunction, leading to the spectrum of symptoms from subtle cognitive impairment to coma [3]. In cirrhosis, HE is an independent predictor of morbidity and mortality, and its emergence signals a critical clinical deterioration that requires immediate intervention targeting the underlying biochemical cause [3]. Priority Action and Pharmacological Rationale The priority action is to administer prescribed lactulose as ordered. Lactulose is the established first-line therapy for the treatment of an acute episode of overt HE [1]. Its mechanism of action directly addresses the underlying hyperammonemia through several pathways in the gastrointestinal tract. It acidifies the colonic lumen, which converts freely diffusible ammonia (NH₃) into ammonium ions (NH₄⁺) that are trapped in the gut and cannot be reabsorbed into the bloodstream. Additionally, its cathartic effect accelerates bowel transit, reducing the time for bacterial production and absorption of ammonia and other nitrogenous wastes. A systematic review and meta-analysis of randomized controlled trials confirms lactulose’s efficacy as the primary treatment for HE, supporting its use to reverse the neuropsychiatric deterioration observed in this client [1]. Analysis of Incorrect Options - Option 1 (Monitor neurological status and implement safety measures): While monitoring and safety interventions are essential nursing actions for a disoriented client at risk for falls, they are supportive measures that do not address the physiological cause of the deterioration. Managing the underlying hyperammonemia takes precedence to halt and reverse the pathological process. - Option 3 (Restrict dietary protein intake): Historically, protein restriction was advised, but current understanding recognizes that malnutrition is a significant risk factor for poor outcomes in cirrhosis. Precipitating factors for HE recurrence include constipation and dehydration, not simply protein intake . Protein restriction is no longer a first-line or priority intervention for an acute HE episode, as it can worsen sarcopenia without clear benefit in resolving the acute neurotoxicity. - Option 4 (Prepare for potential paracentesis procedure): Paracentesis is a therapeutic procedure for removing ascitic fluid, a common complication of cirrhosis. However, it does not treat the metabolic cause of hepatic encephalopathy. Unless the HE was precipitated by spontaneous bacterial peritonitis (which is not indicated in the scenario), paracentesis is not the priority action for managing the client’s neurological and cognitive decline. Clinical Integration The nurse must recognize that the constellation of symptoms represents a life-threatening, but potentially reversible, metabolic encephalopathy. Administering the prescribed lactulose is the critical action to lower serum ammonia levels and resolve the encephalopathy. This intervention directly targets the central pathophysiological mechanism of the condition, making it the highest priority over supportive or unrelated procedures [1][3].References (research sources) - [1]Systematic Review and Meta-Analysis of Lactulose for the Prevention and Treatment of Hepatic Encephalopathy.Meta-analysis/systematic reviewKasmikha L, Chen X, Serper M, Tapper EB. (2026) · DOI: 10.1111/liv.70765 - [3]New insight on hepatic encephalopathy: a comprehensive review.Research articleSedik AA, Alrefaei R. (2026) · DOI: 10.1515/jbcpp-2025-0166 ## 임상 시나리오 Managing Acute Hepatic EncephalopathyPrioritizing Lactulose to Target Hyperammonemia In a client with cirrhosis presenting with lethargy, disorientation, and asterixis, the priority is to administer lactulose. This directly targets the underlying hyperammonemia by acidifying the colon to trap ammonia and exerting a cathartic effect to expel it. Lactulose is titrated to achieve 2 to 3 soft bowel movements per day. Improvement in mental status confirms the diagnosis and treatment efficacy. Supportive measures like safety precautions are secondary to this specific pharmacological intervention. CautionDo not delay lactulose administration for neuro checks or protein restriction. Routine dietary protein restriction is no longer recommended as it worsens malnutrition without clear benefit in acute HE. Monitor for over-diarrhea which can cause dehydration and electrolyte imbalance. ## 핵심 개념 - **Hepatic Encephalopathy** — A neuropsychiatric syndrome caused by liver dysfunction, leading to the accumulation of gut-derived neurotoxins like ammonia in the systemic circulation, resulting in altered mental status and asterixis. - **Asterixis** — A flapping tremor of the hands when wrists are extended, characterized by brief, arrhythmic lapses in sustained posture; a classic sign of metabolic encephalopathy including hepatic encephalopathy. - **Lactulose** — A non-absorbable disaccharide that acidifies the colon, converting ammonia (NH3) to ammonium (NH4+) which is trapped in the gut and excreted, thereby lowering serum ammonia levels. - **Hyperammonemia** — An elevated level of ammonia in the blood, the central pathophysiological driver of hepatic encephalopathy, resulting from the liver's inability to convert ammonia to urea. ## 같은 주제 문제 - [A nurse is assessing a 55-year-old client with end-stage cirrhosis. 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