A nurse is admitting a middle adult client who has cirrhosis. Findings upon admission:

Exhibits

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

Answer and Explanation

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

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

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

A. Disoriented to person, place, and time B. Oxygen saturation 96% at 2 L/min via nasal cannula C. Hct 45% D. Butterfly rash E. Blood pressure 100/50 mm Hg

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

Alterations in level of consciousness is an indicator that the client is in septic shock due to systemic spread of the urinary tract infection

Hematocrit level is normal. Changes in hematocrit levels are not expected in UTI unless the client has hematuria.

A butterfly rash is commonly seen in autoimmune conditions like lupus.

The decrease in oxygen requirements indicates improvement in level of distress and hence improving sepsis

A drop in the systolic blood pressure may indicate that the client is going into septic shock

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

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