The nurse has reviewed the laboratory results day 1 at 1800.
Complete the following sentence by using the lists of options.
The client is at risk for
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Place monitoring cords and tubes in a stockinette: Clients with latex allergies are at risk for serious reactions from contact with latex-containing equipment. Covering cords and tubing with a stockinette helps prevent direct skin exposure to latex, reducing the risk of an allergic reaction.
B. Schedule the client for the last surgery of the day: Clients with latex allergies should be scheduled as the first surgery of the day to minimize their exposure to airborne latex particles and reduce contamination from previously used equipment or surfaces.
C. Choose rubber injection ports for fluid administration: Rubber injection ports often contain latex, which can trigger severe allergic reactions. For clients with latex allergies, non-latex or latex-free alternatives must be used for all fluid and medication administration.
D. Have phenytoin IV readily available: Phenytoin is an anticonvulsant used to manage seizures and is not specifically indicated for treating allergic reactions. Epinephrine, antihistamines, and corticosteroids should be available in case of an anaphylactic reaction.
Correct Answer is C
Explanation
Rationale:
A. "I'm concerned because I'm so tired all the time.": Fatigue is a common manifestation of SLE caused by chronic inflammation, anemia, or medication effects. While it impacts daily function, it is not an immediate threat compared to signs of infection, which can become life-threatening quickly in immunosuppressed clients.
B. "I feel like I'm isolated from all my friends now.": Emotional concerns like isolation are important in managing chronic illness, but they are not urgent physical issues. Addressing psychosocial health is necessary, but it does not take precedence over symptoms that may indicate infection or disease flare.
C. "I've had a fever the last couple of days.": Fever is a priority concern in clients with SLE as it may signal an active infection or disease flare. Immunosuppressive therapy increases the risk of severe infections, which can rapidly worsen if not treated promptly, making this the most urgent issue.
D. "I have a lot of questions about this disease.": Education is vital for long-term disease management and patient empowerment. However, it is not an immediate priority when signs of acute illness, such as fever, are present and require prompt clinical attention.
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