A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?

Encourage short periods of ambulation.

Administer antibiotics.

Restrict fluids.

Provide a diet high in fat.

Answer and Explanation

The Correct Answer is A

A) Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B.
B) Antibiotics are not effective against viruses like hepatitis B.

C) There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function.

D) A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.

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Correct Answer is A

Explanation

A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.

B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.

A. Assess level of consciousness B. Assess for bleeding C. Measure abdominal girth D. Auscultate bowel sounds

Correct Answer is A

Explanation

A) Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B) The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C) This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D) While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.

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A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Correct Answer is A

Explanation

A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Correct Answer is A

Explanation

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