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.
Spontaneous bruising
Ascites
Increased albumin level
Hematemesis
Elevated iron levels
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}
Liver cirrhosis interferes with the synthesis of clotting factors in the liver leading to bleeding as evidence by the spontaneous bruises
The development of ascites occurs as the cirrhotic process progresses leading to increased extravasation of fluid in the splanchnic circulation.
Increased albumin indicates that the synthetic role of the liver is improving. Albumin is synthesized in the liver parenchyma.
Hematemesis occurs due to the presence of esophageal varices as a complication of advanced liver cirrhosis
The liver plays a key role in formation of ferritin which binds iron. Decreased levels of ferritin may lead to increased levels of free iron in the blood
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Extreme temperatures, both hot and cold, can trigger sickle cell crises in individuals with sickle cell disease. Cold temperatures can cause vasoconstriction and increase the risk of sickling of red blood cells, while hot temperatures can lead to dehydration. Therefore, clients with sickle cell disease should avoid exposure to extreme temperatures and take precautions to maintain a comfortable environment, especially during hot summer months and cold winter seasons.
A. Clients with sickle cell disease are at increased risk of developing complications from influenza (flu) infections. Therefore, it is highly recommended that clients with sickle cell disease receive an annual flu vaccination to reduce their risk of contracting the flu and its associated complications.
B. Hydration is crucial for individuals with sickle cell disease as it helps prevent dehydration and reduces the risk of sickling of red blood cells, which can trigger a sickle cell crisis.
C. Alcohol can exacerbate dehydration and increase the risk of vaso-occlusive crises in individuals with sickle cell disease.
Correct Answer is D
Explanation
D. Obtaining an electrocardiogram (ECG) is the first action to take when managing a client with an electrical shock injury. Electrical shock injuries can cause cardiac dysrhythmias, including ventricular fibrillation or other life-threatening arrhythmias. Therefore, obtaining an ECG allows for prompt assessment of cardiac rhythm and identification of any dysrhythmias that may require immediate intervention.
A. While fluid resuscitation may be necessary in the management of electrical shock injuries to address hypovolemia and promote renal perfusion, titrating IV fluids to maintain a specific urine output is not the first action to take.
B. Pain management is important in the care of clients with electrical shock injuries, but it is not the first action to prioritize
C. Changing dressings over the entrance and exit wounds is important for wound care, but it is not the first action to take.
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