A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?

Choice A Reason:

Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) is incorrect. Bilirubin levels within the normal range typically indicate normal liver function. The value of 1.0 mg/dL falls within the expected range, so it doesn't raise immediate concerns regarding the need for a liver biopsy.

Choice B Reason:

Aspartate aminotransferase 34 units/L (0 to 34 units/L) is incorrect. Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver, heart, muscles, and red blood cells. While a value of 34 units/L is at the upper limit of the normal range, it's still within the expected range and doesn't typically prompt immediate concern for the need for a biopsy.

Choice C Reason:

Ammonia 55 mcg/dL (10 to 80 mcg/dL ) is incorrect. Ammonia levels can rise in cases of liver dysfunction. The level of 55 mcg/dL falls within the reference range, indicating normal or near-normal ammonia levels, which doesn't usually necessitate an urgent liver biopsy.

Choice D Reason:

Platelets 60,000/mm3 (150,000 to 400,000/mm3) is correct. Platelets are crucial for blood clotting. A significantly low platelet count, such as 60,000/mm3, termed thrombocytopenia, can indicate compromised clotting ability, which might pose a risk of bleeding during or after a liver biopsy. In the context of a liver biopsy, a low platelet count warrants attention and consideration before proceeding with the procedure to prevent excessive bleeding or complications.

Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.