A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for the halo sign.

Ask the client to blow his nose.

Notify the physician.

Suction the nostril.

Answer and Explanation

The Correct Answer is A

Choice A reason:Testing the drainage for the halo sign is the first action the nurse should take, as clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak, which contains glucose.

Choice B reason:Asking the client to blow his nose could potentially increase the risk of infection or worsen a CSF leak and is not recommended as a first action.

Choice C reason:While notifying the physician is important, it should be done after confirming whether the drainage is CSF, which would require immediate medical intervention.

Choice D reason:Suctioning the nostril is not the first action to take, as it could potentially disrupt the site of the leak and is not diagnostic of a CSF leak.

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Correct Answer is ["A","B","D"]

Explanation

Title: Choice A reason: Beta-blocking agent Beta-blocking agents are often used in the management of cirrhosis of the liver. They are particularly useful in managing portal hypertension, a common complication of cirrhosis. Beta-blockers lower elevated portal pressure and protect against variceal hemorrhage, a serious complication of portal hypertension. Therefore, a beta-blocking agent may be ordered for a client with cirrhosis of the liver.

Title: Choice B reason: Diuretic Diuretics are commonly used in the management of fluid retention, a frequent complication in patients with cirrhosis. Fluid retention can lead to conditions such as ascites (abdominal fluid accumulation) and edema (swelling in the legs, feet, or ankles)2. Diuretics help to remove excess fluid from the body, thereby managing these symptoms. Therefore, a diuretic may be ordered for a client with cirrhosis of the liver.

Title: Choice C reason: Opioid analgesic While opioid analgesics are powerful pain relievers, they should be used with caution in patients with cirrhosis of the liver. Opioids can precipitate hepatic encephalopathy, a condition characterized by altered mental status and neuromuscular dysfunction, which is a serious complication of cirrhosis. Therefore, an opioid analgesic may not be the best choice for a client with cirrhosis of the liver.

Title: Choice D reason: Lactulose Lactulose is a non-absorbable sugar that is widely used in the treatment of hepatic encephalopathy, a common complication in patients with cirrhosis. It works by reducing the absorption of ammonia in the gut, thereby lowering blood ammonia levels and improving symptoms of hepatic encephalopathy. Therefore, lactulose may be ordered for a client with cirrhosis of the liver.

Title: Choice E reason: Sedative Sedatives should be used with caution in patients with cirrhosis of the liver. Like opioids, they can precipitate hepatic encephalopathy. Therefore, a sedative may not be the best choice for a client with cirrhosis of the liver.

A. Evaluate for asterixis B. Palpate for peripheral edema C. Evaluate for decreased level of consciousness D. Inspect for petechiae

Correct Answer is B

Explanation

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.

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A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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?

Correct Answer is B

Explanation

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