A client with liver disease presents with the following laboratory results: serum albumin 4.6 g/dL (normal range: 3.5-5.5 g/dL), serum ammonia 62 mcg/dL (normal range: 15-45 mcg/dL), hematocrit 41% (normal range: 37-47%), PT 13 seconds (normal range: 11-12.5 sec). Which assessment findings are consistent with these values?
Petechiae and bruising
Jaundice and pruritus
Dyspnea and fatigue
Asterixis and confusion
The Correct Answer is D
Choice A reason: Petechiae and bruising could be related to low platelet counts or clotting issues, but they are not directly indicated by the provided lab values.
Choice B reason: Jaundice and pruritus are symptoms associated with liver disease but are not specifically indicated by the lab values provided.
Choice C reason: Dyspnea and fatigue could be symptoms of many conditions, including liver disease, but they are not directly indicated by the lab values provided.
Choice D reason: Asterixis, a flapping tremor of the hands, and confusion are signs of hepatic encephalopathy, which can be associated with elevated serum ammonia levels, as indicated by the lab results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Sodium restriction is a standard intervention in the management of cirrhosis, particularly when there is fluid retention leading to a distended abdomen (ascites) and weight gain.
Choice B reason: Encouraging fluids would not be appropriate for a client with cirrhosis who is already experiencing fluid overload, as indicated by a distended abdomen and weight gain.
Choice C reason: Checking lipase levels is associated with pancreatic function and would not be a direct intervention based on the symptoms of cirrhosis presented.
Choice D reason: Pancrealipase is used to aid digestion in patients with pancreatic insufficiency and is not related to the management of cirrhosis symptoms such as ascites and dyspnea.
Correct Answer is A
Explanation
Choice A reason: In sepsis, inflammatory mediators cause vasodilation and increased capillary permeability, leading to fluid leaking out of the vascular space, resulting in hypotension.
Choice B reason: Platelet aggregation and thrombus formation can occur in sepsis but are more related to disseminated intravascular coagulation (DIC) rather than directly causing hypotension.
Choice C reason: Decreased blood glucose and oliguria can be consequences of sepsis but are not the primary pathophysiological processes responsible for hypotension.
Choice D reason: Hypoxemia and anaerobic metabolism may result from the effects of sepsis on the body, including hypotension, but they are not the direct cause of hypotension.
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