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The nurse has reviewed the laboratory results day 1 at 1800.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for

due to

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Rationale:

  • Hepatic encephalopathy: This is caused by the buildup of neurotoxins, particularly ammonia, due to impaired liver function. The client’s elevated ammonia level and history of chronic alcohol use and jaundice support this diagnosis. Early signs may include confusion and lethargy, progressing to coma if untreated.
  • Uremic encephalopathy: This condition is caused by accumulation of urea and toxins due to kidney failure. There is no evidence in the case of renal impairment, such as elevated BUN or creatinine levels, making this diagnosis unlikely in the current context.
  • Hypoglycemia: Low blood glucose can cause confusion or altered mental status, but this client’s symptoms and labs do not indicate hypoglycemia. There is no mention of a low glucose level, and the focus of concern is more aligned with liver failure than endocrine causes.
  • Abdominal pain: Although abdominal pain is a relevant symptom in liver disease, it is nonspecific and not directly responsible for hepatic encephalopathy. It reflects general liver inflammation or ascites but does not cause neurologic symptoms on its own.
  • Albumin 3.0 g/dL: Low albumin indicates reduced liver synthetic function and contributes to fluid shifts like ascites, but it is not neurotoxic. It does not directly cause hepatic encephalopathy or altered mental status.
  • Ammonia 150 mcg/dL: This is a critically elevated value, more than double the normal upper limit. High ammonia levels are the most direct biochemical cause of hepatic encephalopathy and require immediate treatment to prevent worsening neurological decline.
  • Total Bilirubin 2.0 mg/dL: While elevated bilirubin suggests cholestasis and impaired liver clearance, it leads to jaundice rather than mental status changes. It reflects liver dysfunction but is not the key factor in encephalopathy development.


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Related Questions

Correct Answer is D

Explanation

Rationale:
A. "I can resume sexual intercourse in 48 hours.": Sexual intercourse should be avoided for approximately 3 to 4 weeks after a LEEP to allow proper healing of the cervix and reduce the risk of infection or bleeding. Resuming sexual activity too soon can disrupt tissue recovery.

B. "I can expect some heavy vaginal bleeding for 24 hours.": Heavy vaginal bleeding is not expected after a LEEP and should be reported promptly. Light spotting or a brownish discharge for a few days is normal, but significant bleeding can indicate complications.

C. "I can use tampons when my period comes in a week.": Clients are advised to avoid inserting anything into the vagina, including tampons, for several weeks post-procedure. This helps prevent infection and allows the cervical tissue to heal fully.

D. "I may have mild cramping for several hours.": Mild cramping for a few hours after the procedure is a common and expected response due to cervical manipulation. This symptom typically resolves on its own or with over-the-counter pain relief.

Correct Answer is D

Explanation

Rationale:
A. Give each screw a quarter turn daily using the wrench provided: Clients should never adjust or tighten the halo device screws themselves. Only trained medical professionals should handle adjustments to avoid misalignment or injury to the cervical spine.

B. Apply powder liberally under the chest portion of the halo fixator device: Powder can cake and irritate the skin or lead to moisture buildup, increasing the risk of skin breakdown or infection. The skin under the vest should be kept clean and dry, not powdered.

C. Avoid the use of straws when drinking liquids: Clients can safely use straws to drink fluids while wearing a halo device. There is no contraindication for using a straw, and it may actually make drinking easier.

D. Place a small pillow under the head while lying supine: Using a small pillow supports neck alignment and promotes comfort without compromising the stability of the halo device. This is an appropriate and recommended practice during rest.

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