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A nurse is caring for a client who has cirrhosis of the liver.

Exhibits

Which of the following assessment findings require immediate follow-up? Select all that apply.

Temperature

Bilirubin

Blood pressure

Scattered ecchymosis on the upper limbs

Ammonia level

Abdominal girth

Asterixis

Answer and Explanation

Correct Answer : C,E,G

A. Temperature (96.9°F / 36°C) – Mild hypothermia, but not immediately life-threatening; does not require immediate follow-up.

B. Bilirubin (6.2 mg/dL) – Significantly elevated and indicates worsening liver function, but this is expected in cirrhosis and does not require immediate action unless accompanied by signs of acute liver failure.

C. Blood pressure (82/58 mm Hg) – Requires immediate follow-up as this indicates hypotension, which can be due to complications like sepsis, hepatorenal syndrome, or third-spacing from ascites.

D. Scattered ecchymosis – Indicates coagulopathy, which is common in cirrhosis; important but not immediately life-threatening unless active bleeding is present.

E. Ammonia level (78 mcg/dL) – Requires immediate follow-up. This is markedly elevated and correlates with hepatic encephalopathy, especially in the presence of neurologic symptoms.

F. Abdominal girth increase – Suggests worsening ascites; needs management but not as urgent as hemodynamic instability or encephalopathy signs.

G. Asterixis (flapping tremor) – Requires immediate follow-up. This is a classic sign of hepatic encephalopathy, which can progress rapidly and lead to coma if untreated.

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[73.328125,113.328125],\"yRanges\":[281,321]}"

Explanation

This is where the left dorsalis pedis artery runs and is the most distal pulse that can be palpated on the lower extremity. Assessing it helps determine adequate peripheral circulation post-procedure and ensures there is no arterial compromise due to catheterization.

A. Urine output B. Weight C. Heart rate D. Blood pressure

Correct Answer is C

Explanation

A. Urine output should increase with adequate fluid replacement, not decrease.
B. Weight may increase with fluid resuscitation due to fluid accumulation; a decrease is not a reliable sign of adequate resuscitation in the acute phase.
C. Heart rate. In burn patients, tachycardia is often a compensatory response to hypovolemia. A decrease in heart rate indicates improving circulatory volume and perfusion, suggesting effective fluid resuscitation.
D. Blood pressure should increase or stabilize with adequate fluids; a decrease suggests inadequate perfusion or ongoing hypovolemia.

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A nurse is caring for a client who has cirrhosis of the liver. Exhibits Which of the following assessment findings require immediate follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[73.328125,113.328125],\"yRanges\":[281,321]}"

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client who has cirrhosis of the liver.

Exhibits

Which of the following assessment findings require immediate follow-up? Select all that apply.