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

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

Rationale:

A. While generalized itching is a common symptom of cholestasis in cirrhosis due to bile salt accumulation, it is primarily a quality-of-life issue rather than an immediate threat to life or organ function. Interventions such as antihistamines or bile acid sequestrants can be initiated, but this does not require urgent follow-up.

B. The client’s ammonia level is 95 mcg/dL (normal 10–80 mcg/dL), indicating hyperammonemia. Elevated ammonia is a hallmark of hepatic encephalopathy, which can progress rapidly to confusion, disorientation, stupor, and coma if not addressed promptly. Immediate interventions may include lactulose administration to reduce ammonia absorption, identifying and treating precipitating factors (such as infection, GI bleeding, electrolyte disturbances), and close neurological monitoring. Delaying action can result in life-threatening complications.

C. The client’s blood pressure is 82/58 mm Hg, which is significantly below the normal range. Hypotension in a client with cirrhosis may indicate complications such as hypovolemia from ascites fluid shifts, sepsis, or hepatorenal syndrome. Low perfusion can rapidly compromise organ function, including renal and cerebral perfusion, and requires urgent fluid resuscitation, hemodynamic monitoring, and identification of the underlying cause.

D. Asterixis is a neurological sign of hepatic encephalopathy, reflecting impaired cerebral function due to the accumulation of neurotoxins like ammonia. Its presence along with the elevated ammonia level suggests that the client is at risk of rapid neurologic deterioration. Immediate follow-up is warranted to prevent progression to severe encephalopathy, respiratory compromise, or coma.

E. Rapid increase in abdominal girth indicates worsening ascites. While important to monitor, it is usually a gradual process and does not require immediate emergency intervention unless it causes respiratory compromise, tense ascites, or spontaneous bacterial peritonitis.

F. This finding indicates a coagulopathy, commonly seen in cirrhosis due to decreased synthesis of clotting factors. While it reflects an increased bleeding risk, it is not immediately life-threatening and can be addressed through coagulation studies and appropriate management.

G. The total bilirubin is extremely elevated at 12 mg/dL (normal 0.3–1.0 mg/dL), reflecting significant hepatic dysfunction. While this is concerning and indicates worsening liver failure, bilirubin itself does not require immediate intervention unless it contributes to complications such as encephalopathy or biliary obstruction.

H. The client’s temperature is 36°C (96.9°F), which is slightly below normal. Mild hypothermia may occur in advanced liver disease but is not immediately critical. It should be monitored and addressed if it worsens or is accompanied by other signs of sepsis or shock.