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A nurse is caring for a newly admitted client.

A nurse notes the client's condition and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition:
Encephalopathy

Rationale: The client is disoriented and agitated, with a history of cirrhosis and significantly elevated ammonia (236 mcg/dL), which are hallmark signs of hepatic encephalopathy. Other lab abnormalities (elevated AST, ALT, bilirubin, low albumin) support advanced liver dysfunction.

Actions to Take:

Administer lactulose as prescribed – Lactulose reduces ammonia absorption in the gut, helping to lower serum ammonia levels and improve mental status in hepatic encephalopathy.
Monitor hematemesis – Clients with liver disease are at risk for gastrointestinal bleeding due to esophageal varices; monitoring for vomiting of blood is crucial to prevent complications.

Parameters to Monitor:

Safety measures – Because the client is disoriented and at risk for falls or injury, monitoring safety is essential.
Intake and output – Monitoring fluid balance is critical in clients with liver disease to assess for dehydration, electrolyte imbalance, and response to therapies like lactulose.

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Correct Answer is C

Explanation

Rationale:

A. Although this client has extensive injuries, her prognosis is extremely poor. According to triage principles in mass-casualty situations, clients with unsurvivable injuries are classified as expectant. They receive comfort care, but immediate life-saving interventions are unlikely to succeed.

B. Fixed and dilated pupils indicate severe brain injury with a poor prognosis. Like the client with massive burns, this client is considered expectant in a mass-casualty triage scenario. Immediate intervention is unlikely to improve survival.

C. This client has a life-threatening but potentially survivable injury. Rapid control of hemorrhage can save the client’s life. According to triage principles, clients with airway compromise, severe bleeding, or shock who are likely to survive with prompt treatment are prioritized for immediate care.

D. This client’s injury is minor and does not pose an immediate threat to life. They can safely wait for care after more critical patients are stabilized.

A. Physical therapy B. Oxygen therapy. C. Daily weights. D. Prone position. E. Feet elevated on pillows

Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. Clients with hepatopulmonary syndrome often experience fatigue and decreased exercise tolerance due to hypoxemia. Physical therapy helps maintain muscle strength, mobility, and overall functional status, supporting recovery and quality of life.

B. Hypoxemia is a hallmark of hepatopulmonary syndrome due to intrapulmonary vascular dilations. Supplemental oxygen is indicated to maintain adequate oxygen saturation and relieve symptoms of dyspnea.

C. Monitoring daily weights helps detect fluid retention, which can occur in clients with liver disease and associated complications such as ascites. Tracking weight changes is important for managing fluid balance.

D. Prone positioning is not typically indicated for hepatopulmonary syndrome unless the client has acute respiratory distress requiring advanced interventions. It is not a standard part of routine care.

E. Elevating the feet does not address hypoxemia or pulmonary issues associated with hepatopulmonary syndrome. It may be used for edema management in other contexts but is not a primary intervention for this condition.

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Naxlex Comprehensive Predictor Exams

The following clients come to the emergency department for treatment after a building explosion and collapse. Which client should receive priority care?

Correct Answer is C

Explanation

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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