# Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense ascites and mild confusion. He weighs 72 kg, has no peripheral edema, and has had no alcohol for 2 weeks. He takes spironolactone 100 mg and furosemide 40 mg daily, and lactulose three times a day. Before discharge his serum sodium is 133 mEq/L (normal 135–145 mEq/L), and he is alert and oriented. Which statement by the client shows that diet teaching was understood?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630295  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense ascites and mild confusion. He weighs 72 kg, has no peripheral edema, and has had no alcohol for 2 weeks. He takes spironolactone 100 mg and furosemide 40 mg daily, and lactulose three times a day.

Before discharge his serum sodium is 133 mEq/L (normal 135–145 mEq/L), and he is alert and oriented. Which statement by the client shows that diet teaching was understood?

## 보기

1. "Soy sauce is fine because I will not add table salt."
2. "I should stop eating meat and fish to protect my brain."
3. "I can have soup with every meal if I skip bread."
4. "I will eat a small snack with some protein at bedtime." **✔ 정답**

**정답: 4**

## 해설

Protein is not restricted in cirrhosis, even with a history of encephalopathy; about 1.2–1.5 g/kg/day spread through the day, with a late-evening snack, prevents muscle loss. Sodium is limited to about 2 g a day, and fluid is restricted only for marked hyponatremia.

## 심화 해설

Core concept: nutrition in cirrhosis with prior hepatic encephalopathy

This question tests whether the client can apply three intertwined dietary principles after an episode of hepatic encephalopathy: protein is not restricted, sodium is tightly limited, and meal timing matters. The correct statement must reflect all three without falling into common misconceptions.

In cirrhosis, even with a history of hepatic encephalopathy, protein intake of approximately 1.2–1.5 g/kg/day is recommended and should be distributed throughout the day, including a late-evening snack. For this 72 kg client, that is roughly 86–108 g of protein daily. The rationale is twofold. First, cirrhosis drives a state of accelerated starvation: after an overnight fast, the body quickly shifts to gluconeogenesis and muscle protein breakdown, which raises blood ammonia and worsens sarcopenia. A bedtime snack containing protein shortens the overnight catabolic window and provides a steady supply of amino acids without overwhelming hepatic ammonia clearance. Second, restricting protein does not prevent encephalopathy; it worsens malnutrition and muscle wasting, and muscle is a major site of ammonia detoxification. Losing muscle mass reduces the body’s capacity to handle ammonia, paradoxically increasing encephalopathy risk [1][4].

Watch out! The old teaching of “protein restriction for hepatic encephalopathy” is outdated and is a common distractor on licensure exams. Current guidance emphasizes adequate, evenly distributed protein rather than avoidance of meat, fish, or other high-quality sources [1][2].

Sodium restriction is the second pillar. For ascites, sodium is limited to about 2 g (2,000 mg) per day, which is stricter than simply avoiding table salt. Hidden sodium in soy sauce, canned soups, processed meats, and bread is often the main source of excess intake. The client’s serum sodium of 133 mEq/L is mildly low, but this is dilutional hyponatremia from ascites and diuretic use, not a true sodium deficit. Fluid restriction is reserved for marked hyponatremia, generally below 120–125 mEq/L or when the client is symptomatic; at 133 mEq/L with normal mentation, aggressive fluid restriction is not indicated [1][3].

| Option | Why it is incorrect or correct | Key teaching point |
| --- | --- | --- |
| 1. Soy sauce is fine if no table salt | Soy sauce is extremely high in sodium; one tablespoon contains roughly 900–1,000 mg, nearly half the daily limit | Sodium restriction means total dietary sodium, not just added salt |
| 2. Stop eating meat and fish to protect the brain | Reflects outdated protein-restriction belief; meat and fish provide high-quality protein needed to preserve muscle | Protein is not restricted, even after hepatic encephalopathy |
| 3. Soup with every meal if bread is skipped | Broth-based soups are typically high in sodium; skipping bread does not compensate for soup’s sodium load | Hidden sodium in liquids and processed foods must be counted |
| 4. Small snack with protein at bedtime | Correct: provides protein and calories to shorten overnight fasting and reduce muscle catabolism | Late-evening snack is a core nutritional intervention in cirrhosis |

The fourth option is the only one that demonstrates understanding of both adequate protein intake and appropriate meal distribution. It also avoids the sodium pitfalls embedded in the other choices. A late-evening snack might include yogurt, a small sandwich with lean protein, or a protein supplement, always keeping the total daily sodium under 2 g [1][4].

Key point! For a client with cirrhosis, ascites, and prior encephalopathy, the dietary priorities are: adequate protein (1.2–1.5 g/kg/day) spread across meals and a bedtime snack, sodium limited to 2 g/day, and fluid restriction only for marked hyponatremia. Muscle preservation is a therapeutic goal, not a secondary concern, because sarcopenia independently predicts decompensation and mortality [2][3][4].References (research sources)

- [1]Nutritional Management in Cirrhosis and Hepatic Encephalopathy: Current Practices and Expert Opinions of Indian Gastroenterologists.Research articlePadaki NR, Vinayakumar K, Mohapatra J, Roy A, Banerjee A, Kumar K, Sonawale SB, Joshi N. (2026) · DOI: 10.7759/cureus.113933

- [2]Nutritional Management in Liver Cirrhosis: A Combined Systematic Review and Observational Study.Meta-analysis/systematic reviewAmariței V, Gheorghita RE, Caliman Sturdza OA. (2025) · DOI: 10.3390/diseases13090278

- [3]Association of the protein-sodium dietary index with the incidence of clinical decompensation in patients with liver cirrhosis.Research articleLópez-Sánchez M, Talavera JO, García-Milke MDP, Flores M, Ortiz-Olvera N, Moreno-Alcántar R, Morán-Villota S. (2026) · DOI: 10.1016/j.nut.2025.112918

- [4]Burden of malnutrition and sarcopenia in patients with cirrhosis: pathophysiology, assessment, and management.Research articleMiwa T, Shimizu M, Schnabl B. (2026) · DOI: 10.3350/cmh.2025.1126

## 임상 시나리오

Cirrhosis Nutrition TeachingProtein timing and sodium control after encephalopathy
In cirrhosis, even with prior hepatic encephalopathy, protein is not restricted. Target intake is 1.2–1.5 g/kg/day, spread across meals, including a late-evening snack with protein to reduce overnight muscle breakdown and ammonia rise.

Sodium is limited to about 2 g/day to manage ascites. Fluid restriction is generally reserved for marked hyponatremia, not for mild sodium changes such as 133 mEq/L.

CautionDo not restrict protein after encephalopathy; this worsens sarcopenia and reduces muscle ammonia clearance. Avoid hidden sodium sources such as soy sauce and soup, which can exceed the daily limit even without added table salt.

## 핵심 개념

- **Late-evening snack** — A small protein-containing snack before bed that shortens the overnight fasting catabolic window and reduces muscle breakdown and ammonia rise in cirrhosis.
- **Protein requirement in cirrhosis** — Approximately 1.2–1.5 g/kg/day, even with a history of hepatic encephalopathy, to prevent sarcopenia and support ammonia clearance.
- **Sodium restriction in cirrhosis** — Typically limited to about 2 g/day to control ascites and fluid retention.
- **Sarcopenia** — Loss of skeletal muscle mass, which worsens outcomes in cirrhosis because muscle is a major site of ammonia detoxification.
- **Hepatic encephalopathy** — Neuropsychiatric complication of liver failure; protein restriction is no longer recommended because malnutrition increases risk.

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