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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 B

Explanation

Rationale:
A. Pain in this area is more commonly associated with appendicitis, not diverticular disease.
B. Lower left quadrant is the typical site of pain in diverticular disease, especially diverticulitis, because the sigmoid colon (most often affected) is located here.
C. Upper left quadrant; Pain in this area is more often linked to conditions involving the spleen, stomach, or pancreas.
D. Upper right quadrant; Pain here is usually related to gallbladder, liver, or biliary tract disorders.

Correct Answer is B

Explanation

Rationale:

A. This occurs when there is hypoventilation, leading to elevated PaCO2 and decreased pH. In this case, the PaCO2 is low (32 mm Hg) and the pH is high (7.48), so this is not consistent with respiratory acidosis.

B. The high pH (7.48) indicates alkalosis, and the low PaCO2 (32 mm Hg) shows that the alkalosis is caused by excessive exhalation of CO2, characteristic of respiratory alkalosis. The HCO3 is normal, indicating the kidneys have not yet compensated.

C. Metabolic acidosis is characterized by a low pH and low HCO3. Here, the pH is elevated and HCO3 is normal, so this is not consistent with metabolic acidosis.

D. Metabolic alkalosis would present with high pH and elevated HCO3, often due to vomiting or diuretic use. In this scenario, HCO3 is normal, indicating the alkalosis is not metabolic in origin.

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