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 B
Explanation
B. Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
A. While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
C. Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
Correct Answer is D
Explanation
D. After treatment for primary syphilis, it is essential for the client to have follow-up blood tests to monitor their response to treatment and ensure that the infection has been adequately treated. The follow-up blood tests are typically performed at 3, 6, and 12 months after treatment to check for resolution of the infection.
A. Syphilis is caused by a bacterial infection, not a virus. Therefore, antiviral medications are not effective for treating syphilis.
B. Cryotherapy, which involves freezing off warts or abnormal tissue, is not a treatment for syphilis.
C. Monitoring for 15 minutes after receiving each medication dose is a standard precaution for certain medications, such as vaccines or allergy injections, to monitor for any immediate adverse reactions. However, it is not necessary for syphilis.
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