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.
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Related Questions
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.
Correct Answer is A
Explanation
A) Spironolactone is a potassium-sparing diuretic commonly used to manage fluid retention in liver cirrhosis. The nurse should monitor the client's serum potassium levels regularly as this medication can cause hyperkalemia (elevated potassium levels). It is important to assess potassium levels to avoid complications associated with imbalances in potassium levels.
B) Monitoring blood glucose levels is not specifically related to the use of spironolactone in liver cirrhosis. Spironolactone does not have a significant effect on blood glucose levels.
C) Monitoring the white blood cell count is not directly related to the use of spironolactone. White blood cell count is typically monitored to assess for signs of infection or immune system response.
D) Monitoring serum calcium levels is not directly related to the use of spironolactone in liver cirrhosis. Spironolactone does not significantly impact calcium levels in the blood.
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