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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. By directly relaxing vascular smooth muscle is not how lisinopril primarily works; it does not act directly on smooth muscle but rather affects hormonal pathways.
B. By blocking aldosterone from binding to mineralocorticoid receptors is a secondary effect of the angiotensin-converting enzyme (ACE) inhibitors but not the primary action of lisinopril itself.
C. By blocking the movement of calcium ions into arterial smooth muscles describes the action of calcium channel blockers, not ACE inhibitors like lisinopril.
D. By inhibiting the transformation of angiotensin I to angiotensin II is the correct answer because lisinopril inhibits the ACE enzyme, reducing the production of angiotensin II, which lowers blood pressure and decreases strain on the heart.
Correct Answer is D
Explanation
A. Nitrates do not share a cross-sensitivity with penicillin and are safe to use in this client.
B. Tetracycline is a different class of antibiotics and does not have cross-sensitivity with penicillin.
C. Aminoglycosides also do not have cross-sensitivity with penicillin and can be safely administered.
D. Cephalosporins are structurally related to penicillin and have a risk of cross-sensitivity; thus, they should not be given to a client with a history of anaphylaxis to penicillin.
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