A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the client's intake of protein.

Restrict the client's intake of fluids.

Administer vitamin K

Administer diuretics.

Answer and Explanation

The Correct Answer is A

A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.

B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.

C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.

D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Subcutaneous nodules are not typically associated with SLE; they are more characteristic of rheumatoid arthritis.
B. Pitting edema of the hands and fingers is more common in conditions such as heart failure or renal disease, rather than SLE.
C. A grey-colored, non-purpuric papular rash is not characteristic of SLE. SLE rashes are usually different in appearance.
D. A dry, red rash across the bridge of the nose and on the cheeks, commonly referred to as a butterfly rash, is a classic manifestation of SLE.

A. Perform neurovascular checks of the extremities. B. Direct the client to perform exercises of the ankle and toes. C. Instruct the client on use of crutches. D. Medicate the client for pain.

Correct Answer is A

Explanation

A. Performing neurovascular checks of the extremities is critical to detect signs of complications such as impaired circulation or nerve damage, which can occur after orthopedic surgery. This assessment is essential for early identification of potential issues.

B. While performing exercises of the ankle and toes is important for preventing complications like deep vein thrombosis, it is secondary to ensuring neurovascular integrity.

C. Instructing the client on the use of crutches is necessary for mobility and safety, but it follows the priority of monitoring for neurovascular complications.

D. Medicating the client for pain is important for comfort, but addressing potential neurovascular issues is a higher priority in the immediate postoperative period to prevent serious complications.

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A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

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