A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?

Administer pain medication to alleviate discomfort.

Document the findings and continue monitoring the client.

Obtain an order for a liver biopsy to assess liver function.

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is D

A) Pain medication is not appropriate for managing altered mental status and confusion. The priority is to identify and address the underlying cause of the client's symptoms.

B) While documentation and ongoing monitoring are important, the priority is to take immediate action when the client is exhibiting signs of altered mental status. The nurse should promptly notify the healthcare provider for further evaluation and intervention.

C) A liver biopsy is a diagnostic procedure that provides information about the degree of liver damage and fibrosis. However, it is not the first action to take when the client is experiencing altered mental status and confusion. Immediate notification of the healthcare provider is the priority in this situation.

D) Altered mental status and confusion in a client with liver cirrhosis can indicate hepatic encephalopathy, a serious complication of advanced liver disease. Hepatic encephalopathy results from the accumulation of toxic substances in the blood due to impaired liver function. The nurse should prioritize notifying the healthcare provider immediately to initiate appropriate interventions and prevent further deterioration of the client's condition.

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Correct Answer is D

Explanation

A) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not typically associated with difficulty sleeping or shortness of breath.

B) Portal hypertension, a common complication of liver cirrhosis, can lead to the development of ascites and esophageal varices, among other manifestations. It is not the likely cause of the client's difficulty sleeping and shortness of breath.

C) Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease and is not associated with difficulty sleeping or shortness of breath.

D) Hepatopulmonary syndrome is a complication of liver cirrhosis characterized by the development of pulmonary vascular dilation and arteriovenous shunting. This results in impaired oxygenation of blood, leading to difficulty breathing (dyspnea), especially while lying down (orthopnea). Clients with hepatopulmonary syndrome often experience frequent awakenings due to shortness of breath during sleep.

A. Serum potassium levels B. Blood glucose levels C. White blood cell count D. Serum calcium levels

Correct Answer is A

Explanation

A) Spironolactone is a potassium-sparing diuretic commonly used to manage fluid retention in liver cirrhosis. The nurse should monitor the client's serum potassium levels regularly as this medication can cause hyperkalemia (elevated potassium levels). It is important to assess potassium levels to avoid complications associated with imbalances in potassium levels.

B) Monitoring blood glucose levels is not specifically related to the use of spironolactone in liver cirrhosis. Spironolactone does not have a significant effect on blood glucose levels.

C) Monitoring the white blood cell count is not directly related to the use of spironolactone. White blood cell count is typically monitored to assess for signs of infection or immune system response.

D) Monitoring serum calcium levels is not directly related to the use of spironolactone in liver cirrhosis. Spironolactone does not significantly impact calcium levels in the blood.

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A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?

Correct Answer is D

Explanation

A client with liver cirrhosis is prescribed spironolactone to manage fluid retention. Which laboratory test should the nurse monitor closely while the client is on this medication?

Correct Answer is A

Explanation

A client with liver cirrhosis is at risk of developing esophageal varices. Which medication should the nurse expect to be prescribed to reduce the risk of bleeding from these varices?

A nurse is caring for a client with liver cirrhosis and notices that the client's platelet count is significantly decreased. Which complication of liver cirrhosis is the likely cause of this finding?

A client with liver cirrhosis presents with severe ascites. Which procedure should the nurse anticipate being performed to drain the accumulated fluid from the peritoneal cavity?

A client with liver cirrhosis has developed ascites. Which nursing intervention is a priority for managing this complication?

A client with a history of chronic hepatitis C infection asks the nurse about the risk of developing liver cirrhosis. Which response by the nurse is accurate?

A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?

A client with liver cirrhosis is found to have elevated iron levels in their blood. Which genetic disorder should the nurse suspect as a possible cause of these findings?

A nurse is reviewing the laboratory results of a client suspected to have liver cirrhosis. Which finding should the nurse expect to be elevated, indicating impaired liver function?