A nurse is assisting in the care of a client. Nurses' Notes 2000:

Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room.

2015:

"Client states they were out with friends this evening and had "a little too much to drink." Client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." Client reports history of depression. Client is a full-time college student who lives with roommates. Client admits to drinking socially but denies illicit drug use and tobacco use.

Which of the following interventions should the nurse plan to implement?

Select all that apply.

Explanation

D, Elevated ammonia

Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.

Elevated amylase in (option A) is incorrect because it is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.

Decreased bilirubin levels in (option B) is incorrect because they are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.

Elevated lipase in (option C) is incorrect because it is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.

The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.

"The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.

"What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.

"Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.