A nurse is admitting a middle adult client who has cirrhosis. Findings upon admission:

Exhibits

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

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Triiodothyronine (T3) is one of the thyroid hormones, and in Graves' disease, there is excessive production of thyroid hormones, including T3. Therefore, T3 levels are often elevated in individuals with Graves' disease due to the hyperthyroid state.
A. Phosphorus levels are typically not significantly affected by Graves' disease.
C. In Graves' disease, there is typically suppression of TSH secretion due to the negative feedback from elevated levels of thyroid hormones. Therefore, TSH levels are typically decreased (low) in individuals with Graves' disease.
D. Calcium levels are typically not directly affected by Graves' disease.

A. Emesis of 250 mL B. Increased respiratory rate to 26/min C. Decreased anxiety D. Decreased urinary output

Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

A nurse is reviewing the client's diagnostic results and vital signs. Exhibits Which of the following actions should the nurse take? Select all that apply.

A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

The nurse is reviewing the client's medical record. Exhibits Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following is correct?

A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?