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 ["69"]
Explanation
Convert the weight from pounds to kilograms
190 lb * (1 kg / 2.2046 lb) = 86.183 kg (rounded to three decimal places)
The recommended dietary allowance (RDA) of protein:86.183 kg * 0.8 g/kg = 68.946 g/day
Rounding to the nearest whole number, the client should receive approximately 69 grams of protein daily.
Correct Answer is C
Explanation
A. Monitoring of vital signs should be more frequent
B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.
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