A nurse is admitting a middle adult client who has cirrhosis. Findings upon admission:
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
Spontaneous bruising
Ascites
Increased albumin level
Hematemesis
Elevated iron levels
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}
Liver cirrhosis interferes with the synthesis of clotting factors in the liver leading to bleeding as evidence by the spontaneous bruises
The development of ascites occurs as the cirrhotic process progresses leading to increased extravasation of fluid in the splanchnic circulation.
Increased albumin indicates that the synthetic role of the liver is improving. Albumin is synthesized in the liver parenchyma.
Hematemesis occurs due to the presence of esophageal varices as a complication of advanced liver cirrhosis
The liver plays a key role in formation of ferritin which binds iron. Decreased levels of ferritin may lead to increased levels of free iron in the blood
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Oliguria can occur in severe cases of left-sided heart failure. When the heart's ability to pump blood forward is compromised, blood flow to the kidneys decreases, leading to decreased urine production.
A. Pedal edema is more commonly associated with right-sided heart failure.
B. Neck vein distention is typically associated with right-sided heart failure where increased pressure in the right side of the heart leads to jugular venous distention
D. Enlarged liver, or hepatomegaly, can occur in right-sided heart failure due to congestion and backup of blood in the hepatic circulation.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}
Explanation
The client's record indicate that they are experiencing a myocardial infarction due to the elevated markers of inflammation, cardiac biomarkers and typical ECG findings.
Management of myocardial infarction includes oxygen supplementation, nitroglycerin, morphine sulphate, beta blocker such as metoprolol and aspirin/clopidogrel
Among the triggers of myocardial infarction can be cardiac dysrhythmias. This can be caused by electrolytes disturbances and hence the need to draw electrolytes.
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