A client with cirrhosis has difficulty arousing and an elevated serum ammonia level. Which situation should the nurse suspect?

• A. The client is avoiding the nurse.
• B. The client\'s morning dose of lactulose was not taken.
• C. The client\'s hepatic function is decreasing.
• D. The client is relaxed and not in pain.

Answer: (C)

Ammonia detoxification and hepatic encephalopathy in cirrhosis. The liver normally converts ammonia into urea for excretion, but with cirrhosis its function is impaired. When detoxification declines, ammonia accumulates and can cross the blood-brain barrier, causing cerebral edema and altered mental status such as difficulty arousing. This neurologic change in a patient with cirrhosis and an elevated ammonia level points to worsening hepatic function and hepatic encephalopathy. Lactulose is used to lower ammonia by acidifying the gut and increasing excretion, so not taking it would also raise ammonia, but the key issue behind the reduced arousal is the liver’s diminished ability to detoxify ammonia. Being avoidant or being relaxed and pain-free don’t explain the neurocognitive changes observed.