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The client has been transferred to the inpatient medical unit and the nurse is preparing the plan of care (POC). For each potential nursing action, click to indicate whether the action is indicated or contraindicated for this client's plan of care. Each row must have only one response option selected.

A.

Assist with ambulation with 1 person assist.

B.

Assess level of consciousness.

C.

Prepare to insert an esophageal balloon tamponade tube.

D.

Encourage a high calorie regular diet.

E.

Monitor for bleeding

Answer and Explanation

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

Rationale:

• Assist with ambulation with 1 person assist: The client has balance disturbances and slurred speech due to alcohol-related neurological impairment and possible hepatic encephalopathy. Ambulation assistance helps prevent falls and injury while promoting mobility. One-person assist is sufficient for safety while encouraging independence.

• Assess level of consciousness: Ongoing neurological monitoring is critical in patients with chronic liver disease and potential hepatic encephalopathy. Changes in orientation, alertness, or responsiveness can indicate worsening liver dysfunction, elevated ammonia levels, or acute complications, necessitating timely intervention.

• Encourage a high calorie regular diet: Chronic alcohol use often leads to malnutrition and protein-calorie deficiency. Providing a high-calorie diet supports nutritional needs, energy balance, and liver recovery while preventing further weight loss and muscle wasting. Dietary modifications are essential for long-term management.

• Monitor for bleeding: The client has coagulopathy indicated by prolonged PT (18 seconds) and elevated INR (2.4). Liver dysfunction reduces clotting factor synthesis, increasing the risk of spontaneous bleeding. Close monitoring for bruising, hematuria, or gastrointestinal bleeding is essential to prevent complications.

• Prepare to insert an esophageal balloon tamponade tube: This procedure is typically reserved for acute variceal bleeding, which the client is not currently experiencing. Inserting a balloon tamponade unnecessarily could cause trauma, esophageal rupture, or worsen coagulopathy. Monitoring for bleeding is indicated instead of prophylactic invasive procedures.


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Related Questions

Correct Answer is B

Explanation

Rationale:
A. Microwave oven: Microwaves do not generate electromagnetic interference strong enough to affect a pacemaker. The client can safely use a microwave without risk to the device’s function.

B. Security wand: Hand-held security wands used in airports or some buildings can emit electromagnetic fields that may interfere with pacemaker function. The client should avoid prolonged or close exposure and notify security personnel about the pacemaker.

C. Toaster: Household appliances such as toasters generate minimal electromagnetic interference and are safe for clients with pacemakers. Normal use does not affect device operation.

D. Electric blanket: Modern electric blankets produce low-level electromagnetic fields that are generally considered safe for pacemaker recipients. Brief, standard use does not interfere with pacemaker function.

Correct Answer is B

Explanation

Rationale:
A. Explain that living wills cannot be followed by emergency personnel: Living wills are legally recognized documents that guide care preferences, but their applicability depends on the patient’s current clinical situation. Blanket statements dismissing the document are inappropriate and may cause mistrust.

B. Seek clarification of the type of advance directive the client has: Different advance directives, such as a living will or a DNR order, provide varying levels of guidance regarding resuscitation. Confirming the specific directive ensures that care aligns with the client’s legally documented wishes. This is the most accurate and patient-centered response.

C. Schedule a client and family conference to review the plan of care: While a conference may be useful for ongoing care planning, it does not immediately address the family’s question about why resuscitation was performed. Immediate clarification is the priority.

D. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: DNR bracelets may indicate resuscitation preferences but are not universally used. Verification should include reviewing the medical record and legal documentation, not solely relying on a bracelet.

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