# Situation: A 62-year-old woman has cirrhosis caused by chronic hepatitis B. Endoscopy shows large esophageal varices that have never bled. She has moderate ascites and takes spironolactone, furosemide, and lactulose. Carvedilol has just been started. On day 3 she becomes confused and has asterixis. The nurse reviews the past 24 hours. Normal ranges: sodium 135–145 mEq/L, potassium 3.5–5.0 mEq/L. Stools: 7 loose, watery stools Weight: 1.6 kg less than the day before Serum sodium 150 mEq/L; serum potassium 3.6 mEq/L Diet: protein 1.2 g/kg/day as ordered, with a bedtime snack Hemoglobin: 10.9 g/dL, unchanged from admission; no melena Medicines given: lactulose, spironolactone, furosemide, and carvedilol; no sedatives Which factor MOST likely triggered the change?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630392  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 62-year-old woman has cirrhosis caused by chronic hepatitis B. Endoscopy shows large esophageal varices that have never bled. She has moderate ascites and takes spironolactone, furosemide, and lactulose. Carvedilol has just been started.

On day 3 she becomes confused and has asterixis. The nurse reviews the past 24 hours. Normal ranges: sodium 135–145 mEq/L, potassium 3.5–5.0 mEq/L.
Stools: 7 loose, watery stools
Weight: 1.6 kg less than the day before
Serum sodium 150 mEq/L; serum potassium 3.6 mEq/L
Diet: protein 1.2 g/kg/day as ordered, with a bedtime snack
Hemoglobin: 10.9 g/dL, unchanged from admission; no melena
Medicines given: lactulose, spironolactone, furosemide, and carvedilol; no sedatives
Which factor MOST likely triggered the change?

## 보기

1. Low potassium from the diuretic therapy
2. The protein content of her ordered diet
3. Dehydration from excess lactulose **✔ 정답**
4. Slow bleeding from the varices

**정답: 3**

## 해설

Lactulose is titrated to 2–3 soft stools a day. Seven watery stools, a 1.6-kg weight drop, and a sodium of 150 mEq/L together show dehydration with hypernatremia from too much lactulose, which is itself a recognized trigger of hepatic encephalopathy. Potassium is normal, the protein intake is the recommended amount, and a stable hemoglobin without melena argues against bleeding; the nurse reports the findings so the lactulose dose and fluids can be adjusted.

## 심화 해설

The most likely trigger
On day 3 she becomes confused and develops asterixis, signs of hepatic encephalopathy. The 24-hour review points to one cause. Seven loose, watery stools, a 1.6-kg weight drop, and a serum sodium of 150 mEq/L together show dehydration with hypernatremia from too much lactulose, which is itself a recognized trigger of hepatic encephalopathy. Lactulose is titrated to about 2–3 soft stools a day; seven watery stools exceed that target. The nurse reports the findings so the lactulose dose and fluids can be adjusted.

How excess lactulose can worsen encephalopathy
Lactulose works by acidifying the colon, which traps ammonia as ammonium so it is excreted in stool, and by speeding transit. When the dose is excessive, the client loses large amounts of free water in watery stool. The result is hypovolemia and hypernatremia. Volume depletion reduces kidney perfusion and can increase ammonia production, and the hyperosmolar state affects brain function directly. In this case the treatment intended to prevent encephalopathy has become its trigger.

| Data | Value | Interpretation |
| --- | --- | --- |
| Stools | 7 loose, watery | Above the 2–3 soft-stool target |
| Weight | 1.6 kg less than the day before | Acute fluid loss |
| Sodium | 150 mEq/L (135–145) | Hypernatremia from free-water loss |
| Potassium | 3.6 mEq/L (3.5–5.0) | Normal |
| Hemoglobin | 10.9 g/dL, unchanged; no melena | Argues against bleeding |

Why the other triggers are less likely
Hypokalemia from diuretics is a known trigger, but her potassium is within the normal range. Dietary protein is not the cause: protein of about 1.2–1.5 g/kg/day is recommended in cirrhosis and is not restricted in encephalopathy, and the bedtime snack helps prevent muscle breakdown. Variceal bleeding is a major trigger, but her hemoglobin is unchanged and there is no melena. No sedatives were given.

Nursing actions
The nurse reports the stool count, weight loss, and sodium level, anticipates a reduction in the lactulose dose and fluid replacement, and monitors mental status, stools, weight, and electrolytes. Diuretics may also be reviewed, since they add to volume loss. Safety measures are in place for the confused client.

Exam takeaway
Watch out Not every encephalopathy question is about protein or bleeding. Check the stool count and sodium: too many watery stools mean the lactulose dose itself may be the trigger.

## 임상 시나리오

Lactulose Overuse and Hepatic EncephalopathyWhen treatment becomes the trigger
Lactulose is titrated to 2–3 soft stools a day. Seven watery stools, a 1.6-kg weight loss, and sodium of 150 mEq/L indicate dehydration with hypernatremia from excess lactulose.

Dehydration and hypernatremia are recognized triggers of hepatic encephalopathy. Potassium is normal, protein intake is at the recommended level, and stable hemoglobin argues against bleeding.

CautionDo not restrict protein in hepatic encephalopathy. Report excess stools and electrolyte changes so the lactulose dose and fluids can be adjusted.

## 핵심 개념

- **Hepatic encephalopathy** — A reversible brain dysfunction in liver failure caused largely by accumulation of ammonia and other toxins.
- **Asterixis** — A flapping tremor of the outstretched hands, a classic sign of hepatic encephalopathy.
- **Lactulose** — A nonabsorbable sugar that acidifies the colon and promotes ammonia excretion in stool.
- **Hypernatremia** — Serum sodium above the normal range, often from loss of free water.

## 같은 주제 문제

- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630291)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630292)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630293)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630294)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630295)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630296)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630297)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630298)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._