A nurse is admitting a middle adult client who has cirrhosis.
Findings upon admission:
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
Findings 24 hr Later: Unrelated to Diagnosis /Indication of Potential Worsening/Indication of Potential Improvement Condition
Elevated iron levels
Increased albumin level
Productive cough
Ascites
Hematemesis
Spontaneous bruising
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
A) Elevated iron levels are directly related to hemochromatosis and could indicate a worsening condition if they continue to rise, as this condition causes iron to accumulate in the body, leading to further liver damage.
B) An increased albumin level could be a sign of potential improvement, as low albumin levels are common in liver disease due to the liver's reduced ability to synthesize proteins.
C) A productive cough may be unrelated to the diagnosis of cirrhosis but could be indicative of an additional respiratory issue that needs to be addressed.
D) Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis and would suggest a potential worsening of the condition.
E) Hematemesis is a serious symptom often associated with advanced liver disease and significant bleeding in the gastrointestinal tract, indicating a potential worsening of the patient's condition.
F) Spontaneous bruising can occur due to decreased production of clotting factors by the liver, also suggesting a worsening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A palpable thrill over the graft site indicates adequate blood flow through the graft.
B. The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C. Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D. A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.
Correct Answer is B
Explanation
A) Offering reassurance about the outcome of the procedure may not address the client's specific fears.
B) Encouraging the client to discuss their concerns allows the nurse to address any misconceptions or fears the client may have and provide appropriate information and support.
C) Assuming the client's fear is related to needles may not be accurate and may not address their specific concerns.
D) Asking the client to explain why they are scared is a good approach, but it may not immediately address their fears or provide the support they need.
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