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.
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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Related Questions
Correct Answer is C
Explanation
A. Tucking the chin when swallowing can help reduce the risk of aspiration in clients with certain conditions, but after a total laryngectomy, clients are at increased risk for aspiration due to altered anatomy and should have thickened liquids to minimize this risk.
B. Clients who have undergone a total laryngectomy may have difficulties with swallowing and are at risk of aspiration. It is not accurate to say they will have no trouble swallowing fluids without proper assessment and adaptation.
C. Adding a thickener to liquids is a recommended intervention to reduce the risk of aspiration in clients who have had a laryngectomy, as thickened fluids are less likely to be aspirated into the lungs compared to thin liquids.
D. Clients who have had a total laryngectomy are still at risk for choking or aspiration due to changes in their swallowing mechanics and altered anatomy. It is important to take preventive measures, such as thickening liquids.
Correct Answer is D
Explanation
A. Metabolic alkalosis is characterized by an elevated pH and elevated bicarbonate, which is not consistent with these ABG values.
B. Respiratory alkalosis presents with an elevated pH and decreased PaCO2, opposite of the client's findings.
C. Metabolic acidosis would show a decreased pH with a low bicarbonate level, but this client's bicarbonate is within normal range.
D. Respiratory acidosis is indicated by a low pH and elevated PaCO2 due to hypoventilation, which aligns with the client's ABG values and respiratory rate.
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