A nurse is caring for a newly admitted client.
The Correct Answer is []
Rationale:
- Potential Condition: The client with cirrhosis shows elevated ammonia (236 mcg/dL), confusion, agitation, and disorientation, which are classic findings of hepatic encephalopathy.
- Actions to Take:
- Lactulose is given to lower ammonia levels by promoting its excretion through the stool.
- Assessing for asterixis (flapping tremor of the hands) is key in identifying worsening encephalopathy.
- Parameters to Monitor:
- Neurologic status (orientation, cognition, responsiveness) should be monitored closely to evaluate improvement or deterioration.
- Safety measures are essential because confusion and agitation increase the client’s risk for falls and injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Dietary sources of fiber should not be eliminated; in fact, fiber from food complements the effect of psyllium and supports normal bowel function.
B. Fiber-containing laxatives can have adverse effects, such as bloating, gas, or, rarely, intestinal obstruction if not taken with adequate fluid.
C. Psyllium does not significantly reduce absorption of fat-soluble vitamins; this concern is more relevant to certain other medications, like cholestyramine.
D. Psyllium absorbs water in the intestines, forming a bulky stool. To prevent fecal impaction or bowel obstruction, it is essential to take large amounts of fluid when using this type of laxative.
Correct Answer is ["D","E","F"]
Explanation
Rationale:
- Improved breathing indicates that the removal of ascitic fluid has relieved diaphragmatic pressure, allowing better lung expansion.
- Decreased abdominal pressure demonstrates that fluid removal has reduced intra-abdominal tension, improving mobility and comfort.
- Relief of abdominal discomfort is a primary goal of paracentesis, as it enhances quality of life and reduces pain caused by fluid accumulation.
- Stable vital signs and absence of respiratory distress are important for monitoring safety but are not direct measures of the procedure’s effectiveness.
- Reduced ascitic fluid volume is the mechanism of action of paracentesis, while the client’s symptomatic relief is the best indicator of clinical success.
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