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For each client assessment finding below, click to specify if the finding is consistent with cirrhosis or viral hepatitis: Each finding may support more than one disease process

Exhibits

A.

Report of pain

B.

Eye sclera finding

C.

Alcohol intake history

D.

Report of energy level

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}

Rationale:

  • Report of pain: Abdominal pain is common in both cirrhosis and viral hepatitis due to liver inflammation, capsule stretching, or complications like ascites. In hepatitis, pain is often acute and located in the right upper quadrant, while in cirrhosis, it may be more generalized or related to portal hypertension.
  • Eye sclera finding: Jaundice, noted as yellowing of the sclera, occurs in both conditions due to impaired bilirubin metabolism. In cirrhosis, it's due to chronic hepatocellular failure, while in viral hepatitis, it's from acute inflammation impairing bilirubin excretion.
  • Alcohol intake history: A 25-year history of heavy alcohol use is a strong risk factor for alcoholic cirrhosis. While alcohol use can worsen viral hepatitis, it is not a primary cause of viral hepatitis, which is due to infection with hepatitis viruses (A, B, C, etc.).
  • Report of energy level: Fatigue is a common symptom in both conditions due to impaired liver function, toxin accumulation, anemia, or systemic inflammation. In viral hepatitis, fatigue is often sudden and profound, while in cirrhosis, it is usually chronic and progressive.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. Notify the surgeon of the temperature elevation: While the surgeon may need to be informed if there are signs of infection or persistent fever, the nurse should first gather more data to determine the possible cause of the elevated temperature.

B. Encourage the client to drink more fluids: Increased fluid intake may help reduce mild postoperative fever, especially if it's related to dehydration or atelectasis. However, this is not the priority without assessing for infection first.

C. Assess the surgical incision for signs of infection: The priority is to assess for potential sources of infection, particularly the surgical site, given that the client is 3 days postoperative and has a fever. Early identification of infection is critical to prevent complications such as wound dehiscence or sepsis.

D. Monitor vital signs every 4 hr: Routine monitoring is important but does not take precedence over immediate assessment of the surgical site when there is a concerning temperature elevation. The nurse should act to identify the cause first.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

Rationale:

  • Troponin I level: An elevated troponin I level indicates myocardial cell injury and is a key diagnostic marker for MI. Even a value at the upper limit of normal (0.03 ng/mL) warrants concern, especially with accompanying symptoms.
  • ECG result – sinus tachycardia: Sinus tachycardia is nonspecific but may occur in both MI and angina due to pain, anxiety, or sympathetic stimulation. However, more definitive MI-related changes like ST elevation or Q waves would provide clearer diagnostic value.
  • Heart rate: A heart rate of 116/min is elevated and may represent the body’s response to pain, hypoxia, or stress. This can be seen in both angina and MI, though persistent or worsening tachycardia in MI may indicate hemodynamic instability.
  • Heart palpitations: Palpitations are common during episodes of angina and are often due to increased sympathetic tone or transient arrhythmias. They are usually mild and resolve with rest or nitroglycerin in stable angina.
  • Blood pressure: A blood pressure of 158/92 mm Hg indicates hypertension, a known trigger and risk factor for angina. Elevated BP increases myocardial oxygen demand, potentially precipitating chest pain in those with coronary artery disease.

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