A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
Reduce the client's intake of protein.
Restrict the client's intake of fluids.
Administer vitamin K
Administer diuretics.
The Correct Answer is A
A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.
B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.
C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.
D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hirsutism is more commonly associated with Cushing's syndrome due to excess androgen production. Addison's disease, on the other hand, involves insufficient production of adrenal hormones.
B. Purple striations, or striae, are a characteristic finding in Cushing's syndrome as a result of prolonged exposure to high levels of cortisol, not typically seen in Addison's disease.
C. Hyperpigmentation, particularly in areas exposed to friction or sun, is a hallmark of Addison's disease. This occurs due to increased levels of ACTH, which also stimulates melanocytes.
D. Intention tremors are typically associated with neurological disorders such as multiple sclerosis, and are not a characteristic finding in Addison's disease.
Correct Answer is D
Explanation
A. Eyelets not being visible may be a normal finding, as they can be covered by the dressing. This is not necessarily indicative of a problem with the chest tube.
B. Crepitus, or subcutaneous emphysema, is concerning and should be monitored but is not immediately life-threatening compared to other signs of complications.
C. Bubbling in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning correctly. Continuous bubbling, however, may suggest an air leak.
D. Movement of the trachea toward the unaffected side is indicative of a mediastinal shift, which can occur due to tension pneumothorax or other significant complications. This is an urgent condition that requires immediate provider notification and intervention.
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