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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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Correct Answer is D

Explanation

A. Traveling to an underdeveloped country is more commonly associated with risk for hepatitis A and E due to contaminated food or water, not hepatitis C.
B. Eating raw shellfish is a risk factor for hepatitis A, not hepatitis C.
C. Working in a child care center may increase risk for hepatitis A through fecal-oral transmission, but not hepatitis C.
D. Hepatitis C is primarily transmitted through blood-to-blood contact, and having multiple tattoos, especially if done with non-sterile equipment, increases the risk for hepatitis C infection.

A. PaCO₂ 29 mmHg B. pH 7.30 C. pH 7.40 D. HCO₃⁻ 17 mEq/L

Correct Answer is C

Explanation

A. A PaCO₂ of 29 mmHg indicates respiratory alkalosis, which is not typical in HHS.
B. A pH of 7.30 indicates acidosis, more common in diabetic ketoacidosis (DKA), not HHS.
C. A pH of 7.40 is normal, consistent with HHS where severe acidosis is typically absent.
D. HCO₃⁻ of 17 mEq/L indicates metabolic acidosis, which is more characteristic of DKA rather than HHS.

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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.

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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.