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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Restricting fluid intake is not appropriate for managing ascites in clients with liver cirrhosis. Ascites occurs due to fluid accumulation in the peritoneal cavity and is not primarily influenced by oral fluid intake.
B) Encouraging a high-sodium diet is contraindicated in clients with ascites. High sodium intake can exacerbate fluid retention and worsen ascites. Instead, clients with ascites should be on a low-sodium diet to reduce fluid accumulation.
C) In a client with liver cirrhosis experiencing fluid retention and abdominal distension due to ascites, paracentesis is an essential intervention to drain the accumulated ascitic fluid from the abdominal cavity. Paracentesis helps to relieve discomfort, improve respiratory function, and reduce intra-abdominal pressure.
D) Diuretics are used in the management of ascites to promote urine output and reduce fluid retention. However, paracentesis is a more immediate intervention for relieving discomfort and removing a large volume of ascitic fluid.
Correct Answer is C
Explanation
A) Transient elastography is not used to assess esophageal varices. Endoscopy is the primary method for diagnosing and grading the severity of esophageal varices in clients with liver cirrhosis.
B) Transient elastography is primarily used to assess the degree of liver fibrosis, not to evaluate liver function or enzyme levels. Liver function and enzyme levels are typically evaluated through blood tests, such as liver function tests (LFTs), which measure liver enzymes, bilirubin, albumin, and other markers of liver health and function.
C) Transient elastography is a non-invasive imaging technique used to assess liver stiffness, which correlates with the degree of fibrosis in the liver. It provides information about the presence and severity of liver fibrosis, aiding in the diagnosis and staging of liver cirrhosis.
D) Transient elastography is not used to identify hepatic encephalopathy. Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, and its diagnosis is based on clinical assessment, mental status evaluation, and laboratory tests. Transient elastography is not involved in identifying or diagnosing hepatic encephalopathy.
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