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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. Petechiae are small, red or purple spots caused by capillary bleeding and are common in advanced cirrhosis due to thrombocytopenia and coagulation defects.
B. Peripheral ulcers are not typically associated with cirrhosis.
C. Osteoarthritis is a degenerative joint condition unrelated to liver disease.
D. Hypertension is not a hallmark of advanced cirrhosis; portal hypertension may occur, but systemic hypertension is not expected.

Correct Answer is ["A","C","E"]

Explanation

Rationale:

  • Retaining the fluid allows the enema to soften stool and stimulate peristalsis effectively.
  • Avoiding frequent use prevents dependence and irritation of the bowel.
  • Following provider instructions ensures safe and appropriate selection of enema type and solution for the client’s condition.
  • Electrolyte imbalances, benefits of solutions, and fluid intake are important considerations but are broader teaching points, not immediate enema administration instructions.

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