A client has been admitted with acute liver failure. Which assessment findings are most important concerning?

Jaundiced sclera and skin.

Elevated total bilirubin level.

Asterixis and lethargy.

Liver 3 cm below costal margin.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Jaundice is caused by the accumulation of bilirubin in the blood due to impaired liver function. While it is an important clinical sign of liver dysfunction, jaundice develops gradually and is not an immediate life-threatening complication. It serves more as an indicator of underlying liver disease rather than an urgent signal requiring immediate intervention.

B. Laboratory evidence of elevated bilirubin confirms liver dysfunction but does not provide real-time information about the client’s neurological or hemodynamic status. Lab values are important for diagnosis and monitoring but are less urgent than clinical manifestations of complications such as hepatic encephalopathy.

C. Asterixis, also known as “flapping tremor,” combined with lethargy, is a hallmark sign of hepatic encephalopathy, a serious and potentially life-threatening complication of acute liver failure. These symptoms indicate that neurotoxins, especially ammonia, are accumulating in the brain due to the liver’s inability to metabolize them. Hepatic encephalopathy can rapidly progress from mild confusion to stupor or coma. Early recognition allows timely interventions, such as administering lactulose to reduce ammonia levels, monitoring neurological status, and preparing for possible intensive care support. These findings take priority over laboratory or physical exam findings that are not immediately dangerous.

D. Mild hepatomegaly is common in acute liver failure and may indicate inflammation or congestion. While it is relevant for assessment, it is not an urgent concern compared with neurological changes like asterixis and lethargy.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Pruritus (itching) is a common symptom in viral hepatitis due to bile salt accumulation in the skin resulting from impaired liver function. Itching often worsens at night and can significantly affect comfort. This is an expected finding.

B. Joint pain or arthralgia can occur in viral hepatitis, particularly in hepatitis B and C, due to immune-mediated inflammatory responses. This symptom is consistent with viral infection and liver inflammation.

C. Clients with viral hepatitis may experience anorexia or decreased appetite, but polyphagia (excessive hunger) is not typically associated with viral hepatitis. However, metabolic changes may sometimes alter appetite in early or resolving stages. This is less common but not the most unrelated finding.

D. Skin abrasions are not a direct manifestation of viral hepatitis. They may occur incidentally from trauma or other conditions but are unrelated to liver infection or its typical clinical features. This makes skin abrasions the finding not expected in viral hepatitis.

A. The client develops diarrhea. B. The client has four to five soft bowel movements per day. C. The client's speech becomes clear and appropriate. D. The client develops fetor hepaticus and asterixis

Correct Answer is B

Explanation

Rationale:

A. Lactulose can cause loose stools, but diarrhea is not the desired therapeutic outcome. Excessive diarrhea can lead to dehydration, electrolyte imbalances, and worsening confusion, which are adverse effects rather than expected responses.

B. Lactulose is used to reduce serum ammonia levels in clients with hepatic encephalopathy by promoting excretion of ammonia through the stool. The expected therapeutic outcome is regular, soft bowel movements, typically two to five per day, without causing excessive diarrhea. This indicates that ammonia is being cleared effectively, reducing neurotoxic effects.

C. Improvement in mental status is the ultimate goal of lactulose therapy, but it may take several doses to achieve. Immediate changes in speech are not expected and do not solely indicate treatment effectiveness.

D. Fetor hepaticus (a characteristic musty breath odor) and asterixis (flapping tremor of the hands) are signs of worsening hepatic encephalopathy. Their appearance would indicate treatment failure or progression of disease, not a positive response.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client has been admitted with acute liver failure. Which assessment findings are most important concerning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client being evaluated for viral hepatitis. Which finding is not expected in viral hepatitis?

Correct Answer is D

Explanation

The nurse evaluates a client's response to lactulose treatment. Which finding indicates an expected outcome?

Correct Answer is B

Explanation

A client with acute pancreatitis presents with a board-like abdomen, guarding and absent bowel sounds. What should the nurse be most concerned about?

The nurse provides care to a Muslim client who presents to the emergency department with abdominal pain and vaginal bleeding. The client's spouse asks that only a female examines the client. Which is the most culturally appropriate statement by the nurse in response to the request?

The following clients come to the emergency department for treatment after a building explosion and collapse. Which client should receive priority care?

The nurse teaches a client about strategies for reducing the risk of hepatitis B transmission, which statements by the client indicate understanding? Select all that apply.

A client dies in the emergency department. The client's mother states that she is overwhelmed and doesn't know how to proceed since she has never had a death in the family before. Which action should the nurse avoid?

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? Select all that apply.

The nurse teaches a client with chronic pancreatitis how to monitor the effectiveness of pancreatic enzyme replacement therapy. Which instruction should the nurse include?

A client with end-stage liver failure presents with confusion, lethargy, and asterixis. Which laboratory result is most likely associated with these symptoms?