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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 tall, peaked T wave on an ECG is a classic sign of elevated potassium levels, which can progress to life-threatening arrhythmias if untreated.
B. Hypocalcemia is incorrect; it is associated with prolonged QT intervals and tetany, not peaked T waves.
C. Hyponatremia is incorrect; it typically causes neurologic symptoms (confusion, seizures) rather than characteristic ECG changes.
D. Hypomagnesemia is incorrect; it can cause prolonged QT and torsades de pointes, but not peaked T waves.

Correct Answer is ["15"]

Explanation

Rationale:
Desired dose = 15 mg
Available concentration = 5 mg per 5 mL = 1 mg/mL
Volume needed = Desired dose ÷ Concentration = 15 mg ÷ 1 mg/mL = 15 mL
Rounded to nearest whole number = 15 mL

Final Answer: 15 mL

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