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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Although auscultating breath sounds is important, it is not the immediate priority. The client’s symptoms suggest a possible allergic reaction or anaphylaxis.
B. Elevating the head of the bed is important for comfort but is not the first action in the event of a suspected allergic reaction.
C. Stopping the infusion is the first critical step to prevent further exposure to the allergen and reduce the risk of severe reactions.
D. Calling the provider is important but should occur after ensuring the immediate safety of the client by stopping the infusion.
Correct Answer is B
Explanation
A. While high-fiber foods are generally healthy, they are not specifically targeted to prevent biliary colic. The primary dietary focus should be on fat intake.
B. Avoiding foods high in fat is crucial for clients with chronic cholecystitis, as fatty foods can trigger biliary colic by stimulating the gallbladder to contract.
C. High sodium intake is more related to cardiovascular and kidney health and is not specifically implicated in biliary colic.
D. Including foods high in starch and proteins is not as critical as avoiding fatty foods to prevent episodes of biliary colic.
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