The nurse is caring for a client who has been admitted after an acetaminophen overdose. Which of the nurse's assessment findings suggest liver damage? (Select all that apply.)

The client's skin and eyes are visibly jaundiced.

The client's AST and ALT levels are elevated.

The client's temperature is 102.5° F (39.2° C).

The client has an elevated red blood cell count.

The client's eyes are sensitive to light.

Answer and Explanation

Correct Answer : A,B

A. The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.

B. The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.

C. The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.

D. The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.

E. The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.

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Correct Answer is C

Explanation

A. An allergic reaction is a possible response to medication, but it is not directly related to doubling the dosage.

B. Anaphylactic reaction is a severe and rapid allergic response; while possible, it is not the most likely consequence of an overdose in this context.

C. Poisoning is a likely concern when a client takes double the prescribed dosage of analgesics, especially if the medication has a narrow therapeutic index or is known to cause toxicity at high doses.

D. Sedative effects could occur depending on the analgesic used, but poisoning is a more pressing concern following an overdose.

A. Increased risk for CNS depression B. Respiratory depression C. Opioid withdrawal symptoms D. Hypotension

Correct Answer is C

Explanation

A. An increased risk for CNS depression is not typically associated with opioid agonist-antagonists; instead, these medications may produce a ceiling effect on sedation compared to full agonists.

B. Respiratory depression is more commonly associated with full opioid agonists rather than agonist-antagonists. Agonist-antagonists can sometimes counteract respiratory depression caused by full agonists.

C. Opioid withdrawal symptoms can occur when a client who is dependent on full agonist opioids is given an agonist-antagonist, as these medications can displace the agonist from receptors, leading to withdrawal.

D. Hypotension is a possible side effect of opioids but is not a specific concern with the use of agonist-antagonists in the context of opioid therapy.

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The nurse is caring for a client who has been admitted after an acetaminophen overdose. Which of the nurse's assessment findings suggest liver damage? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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