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A nurse is caring for a client in the emergency room.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale:

  • Potential Condition: The client presents with jaundice, ascites, abdominal distention, confusion, and abnormal liver function tests (elevated AST, ALT, and bilirubin, with low albumin), consistent with cirrhosis and fluid volume excess.
  • Actions to Take:
    • Administer diuretics (such as spironolactone or furosemide) to reduce fluid retention and help manage ascites.
    • Monitor fluid intake and output to evaluate fluid balance and effectiveness of diuretic therapy.
  • Parameters to Monitor:
    • Blood pressure is important because hypotension is present and can worsen with fluid shifts and diuretic therapy.
    • Abdominal girth is monitored to track the progression or reduction of ascites.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Elevated AST indicates hepatocellular injury, but it does not directly reflect fluid volume status.

B. In liver cirrhosis, the liver produces less albumin, leading to reduced plasma oncotic pressure. Low albumin allows fluid to leak into interstitial spaces, causing ascites, edema, and overall fluid volume excess.

C. Prolonged PT reflects impaired clotting factor synthesis in cirrhosis, not fluid status.

D. High bilirubin indicates impaired bile excretion and liver dysfunction, but it is not a direct marker of fluid overload.

Correct Answer is B

Explanation

Rationale:
A. Vomiting is more common in small bowel obstruction and is usually less severe in large bowel obstruction.

B. A large bowel obstruction causes accumulation of gas and fecal material proximal to the blockage, leading to significant abdominal distention.

C. Large bowel obstruction may eventually cause metabolic acidosis due to impaired perfusion and tissue hypoxia, not alkalosis.

D. Back pain is not a typical sign of large bowel obstruction; the primary symptom is abdominal discomfort, distention, and constipation.

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