A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?
Administer pain medication to alleviate discomfort.
Document the findings and continue monitoring the client.
Obtain an order for a liver biopsy to assess liver function.
Notify the healthcare provider immediately.
The Correct Answer is D
A) Pain medication is not appropriate for managing altered mental status and confusion. The priority is to identify and address the underlying cause of the client's symptoms.
B) While documentation and ongoing monitoring are important, the priority is to take immediate action when the client is exhibiting signs of altered mental status. The nurse should promptly notify the healthcare provider for further evaluation and intervention.
C) A liver biopsy is a diagnostic procedure that provides information about the degree of liver damage and fibrosis. However, it is not the first action to take when the client is experiencing altered mental status and confusion. Immediate notification of the healthcare provider is the priority in this situation.
D) Altered mental status and confusion in a client with liver cirrhosis can indicate hepatic encephalopathy, a serious complication of advanced liver disease. Hepatic encephalopathy results from the accumulation of toxic substances in the blood due to impaired liver function. The nurse should prioritize notifying the healthcare provider immediately to initiate appropriate interventions and prevent further deterioration of the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
B) Furosemide is a diuretic used to treat fluid retention in clients with cirrhosis but is not effective in reducing ammonia levels or managing hepatic encephalopathy.
C) Propranolol is a beta-blocker often prescribed to reduce portal hypertension and prevent variceal bleeding in clients with liver cirrhosis. It is not used to treat hepatic encephalopathy.
D) Spironolactone is a diuretic used to manage fluid retention and ascites in clients with liver cirrhosis. Like furosemide, it is not effective in reducing ammonia levels or treating hepatic encephalopathy.
Correct Answer is A
Explanation
A. Encouraging the client to lie on the right side after a liver biopsy is essential because this position helps to apply pressure to the biopsy site, reducing the risk of bleeding.
B. While administering pain medication may be necessary, it is not the primary nursing action following a liver biopsy compared to ensuring hemostasis and preventing complications.
C. Monitoring vital signs is important, but in this case, vital signs should be checked more frequently than every 4 hours to assess for complications like bleeding. Initial monitoring is typically every 15 minutes for the first hour and then every 30 minutes to hourly based on facility protocols.
D. Although maintaining a supine position is typically advised, the focus should be on the right side position to ensure proper hemostasis following the biopsy procedure.
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