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A nurse is caring for a newly admitted client.

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

Answer and Explanation

The Correct Answer is []

Rationale:

  • Potential Condition: The client with cirrhosis shows elevated ammonia (236 mcg/dL), confusion, agitation, and disorientation, which are classic findings of hepatic encephalopathy.
  • Actions to Take:
    • Lactulose is given to lower ammonia levels by promoting its excretion through the stool.
    • Assessing for asterixis (flapping tremor of the hands) is key in identifying worsening encephalopathy.
  • Parameters to Monitor:
    • Neurologic status (orientation, cognition, responsiveness) should be monitored closely to evaluate improvement or deterioration.
    • Safety measures are essential because confusion and agitation increase the client’s risk for falls and injury.


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Related Questions

Correct Answer is A

Explanation

Rationale:
A. The pH of 7.3 indicates acidemia (normal range 7.35–7.45). The PaCO2 of 50 mm Hg is elevated (normal 35–45 mm Hg), indicating a respiratory cause. This combination is consistent with respiratory acidosis.
B. Respiratory alkalosis would present with a high pH and low PaCO2.
C. Metabolic acidosis would show a low pH and low HCO3-.
D. Metabolic alkalosis would show a high pH and elevated HCO3-.

Correct Answer is B

Explanation

Rationale:

A. Restlessness can occur with electrolyte imbalances or hypoxia, but it is not a hallmark of low albumin or protein malnutrition.

B. Low serum albumin and total protein decrease plasma oncotic pressure, allowing fluid to shift from the vascular space into interstitial tissues, leading to peripheral and sometimes generalized edema (anasarca).

C. Pallor is more indicative of anemia, which may coexist but is not a direct effect of hypoalbuminemia.

D. Confusion can result from electrolyte disturbances, hypoxia, or hepatic encephalopathy, but it is not a direct manifestation of low albumin.

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