A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Assess level of consciousness

Assess for bleeding

Measure abdominal girth

Auscultate bowel sounds

Answer and Explanation

The Correct Answer is A

A)   Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B)   The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C)   This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D)   While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.

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Correct Answer is D

Explanation

A) While a high carbohydrate diet can contribute to fatty liver disease, it is less direct and specific compared to other risk factors.
B) Heart disease is not directly linked to liver disease risk.

C) Having a flu is unrelated to liver disease risk.

D) Intravenous drug use is a known risk factor for hepatitis B and C, both of which can lead to liver disease.

A. Risk for bleeding B. Risk for activity intolerance C. Risk for impaired nutrition: less than body requirements D. Risk for impaired skin integrity

Correct Answer is A

Explanation

A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.

B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.

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A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which question would the nurse ask to identify a risk factor for liver disease?

Correct Answer is D

Explanation

A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Correct Answer is A

Explanation

The nurse is preparing discharge teaching for a client who has had a paracentesis. What information should be included in the education session?

The client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?

The nurse is providing care to a client admitted with chronic pancreatitis. Which items are appropriate to include in the discharge teaching for this client? Select all that apply.

What does the nurse identify as a potential complication of chronic pancreatitis?

The nurse is collecting a health history of a client admitted for possible acute pancreatitis. Which health history item would increase the client's risk for this diagnosis?

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

The nurse is preparing a community presentation about hepatitis B virus (HBV). Which information should be included in the teaching session?

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