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.

Answer and Explanation

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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Correct Answer is A

Explanation

A)Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to drain the accumulated fluid in clients with ascites. This procedure is performed to relieve abdominal pressure and discomfort, as well as to facilitate diagnostic testing on the ascitic fluid.

B) Thoracentesis is a procedure to drain fluid from the pleural cavity, which is the space surrounding the lungs. It is not used to treat ascites.

C) Pleurodesis is a procedure performed to create adhesions between the two layers of the pleura to prevent recurrent pleural effusions (fluid accumulation in the pleural cavity). It is not used to treat ascites.

D) Pericardiocentesis is a procedure to drain fluid from the pericardial sac surrounding the heart. It is not used to treat ascites.

A. "Take lactulose with meals to enhance its effectiveness." B. "Expect one to two soft bowel movements per day while on lactulose." C. "Limit your fluid intake while on lactulose to prevent fluid overload." D. "Monitor your blood glucose levels frequently while taking lactulose."

Correct Answer is B

Explanation

A) While lactulose can be taken with meals to minimize gastrointestinal discomfort, its effectiveness is not necessarily enhanced by taking it with meals. The timing and dosage of lactulose should be based on the healthcare provider's instructions.

B) Lactulose is a medication commonly used to manage hepatic encephalopathy in clients with liver cirrhosis. It works by reducing ammonia levels in the blood by promoting the excretion of ammonia through the stool. The nurse should instruct the client to expect one to two soft bowel movements per day while on lactulose, as this indicates the medication's effectiveness in removing ammonia from the body.

C) Lactulose is not associated with fluid overload, and there is no need to limit fluid intake while taking the medication. In fact, adequate hydration is important in clients with liver cirrhosis.

D) Lactulose is not known to significantly affect blood glucose levels, and there is no specific need for the client to monitor blood glucose levels while taking this medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with liver cirrhosis presents with severe ascites. Which procedure should the nurse anticipate being performed to drain the accumulated fluid from the peritoneal cavity?

Correct Answer is A

Explanation

A client with liver cirrhosis is prescribed lactulose to manage hepatic encephalopathy. What should the nurse instruct the client about taking this medication?

Correct Answer is B

Explanation

A client with suspected liver cirrhosis undergoes a liver biopsy. Which nursing action is essential following the procedure?

A client with liver cirrhosis has developed ascites. Which nursing intervention is a priority for managing this complication?

A client with liver cirrhosis is experiencing fluid retention and abdominal distension due to ascites. Which nursing intervention is essential to manage this complication?

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?

A client with liver cirrhosis has been referred for transient elastography. What is the primary purpose of this diagnostic test?

A nurse is reviewing the laboratory results of a client suspected to have liver cirrhosis. Which finding should the nurse expect to be elevated, indicating impaired liver function?

A client with liver cirrhosis is experiencing episodes of hepatic encephalopathy. Which medication should the nurse anticipate administering to help reduce ammonia levels in the blood?

A nurse is providing community education on the risk factors for liver cirrhosis. Which risk factor should the nurse emphasize as the leading cause of liver cirrhosis?