The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
Evaluate for asterixis
Palpate for peripheral edema
Evaluate for decreased level of consciousness
Inspect for petechiae
The Correct Answer is B
Choice A reason: Asterixis, also known as “liver flap,” is a type of tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers. It is associated with hepatic encephalopathy, a condition that can occur with severe liver disease, but it is not a direct indicator of low albumin levels.
Choice B reason: Peripheral edema is a common clinical finding in patients with hypoalbuminemia, which is a low level of albumin in the blood. When albumin levels are low, fluid from the bloodstream can leak into body tissues, causing swelling, especially in the lower limbs. When assessing a client with liver disease and low albumin levels, palpating for peripheral edema would be the most relevant nursing assessment, as it directly correlates with the effects of hypoalbuminemia on fluid balance in the body. Albumin is a protein made by the liver that helps keep fluid in your blood vessels and plays a role in transporting substances throughout your body. Low levels of albumin can lead to fluid leaking out of blood vessels into tissues, causing swelling or edema.
Choice C reason: Decreased level of consciousness can be a sign of various conditions, including hepatic encephalopathy or other complications of liver disease, but it is not specifically indicative of low albumin levels.
Choice D reason: Petechiae are small red or purple spots caused by bleeding into the skin and may be associated with various conditions, including liver disease, but they are not a specific sign of low albumin levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A heart murmur is not a common finding in right-sided heart failure unless there is an associated valvular heart disease.
Choice B reason: Dependent edema is a classic sign of right-sided heart failure due to the accumulation of fluid in the tissues, particularly in the lower extremities.
Choice C reason: Chest pain is more commonly associated with left-sided heart failure or other cardiac conditions such as angina.
Choice D reason: Crackles in the lungs are typically found in left-sided heart failure due to pulmonary congestion, not right-sided heart failure.
Correct Answer is A
Explanation
Choice A reason:Lactulose is used in hepatic encephalopathy primarily to lower blood ammonia levels. It works by converting ammonia in the intestines into ammonium, which is then excreted³. Therefore, a decrease in ammonia levels would indicate the effectiveness of the medication.
Choice B reason:While lactulose can relieve constipation due to its laxative effect, relief of constipation is not the primary indicator of its effectiveness in treating hepatic encephalopathy³.
Choice C reason:Decreased liver enzymes are not a direct measure of lactulose's effectiveness in hepatic encephalopathy. Liver enzymes are indicators of liver function, not ammonia levels³.
Choice D reason:Relief of abdominal pain is not a specific indicator of lactulose's effectiveness in hepatic encephalopathy. The medication's primary role is to reduce ammonia levels, not to alleviate pain³.
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