A nurse is reviewing laboratory findings for three clients.

Which of the following laboratory results should the nurse expect for a client who has cirrhosis?

Elevated amylase

Decreased bilirubin

Elevated lipase

Elevated ammonia

Answer and Explanation

The Correct Answer is D

Explanation

D, Elevated ammonia

Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.

Elevated amylase in (option A) is incorrect because it is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.

Decreased bilirubin levels in (option B) is incorrect because they are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.

Elevated lipase in (option C) is incorrect because it is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.

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Correct Answer is C

Explanation

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

A. Use one client identifier before administering medication B. Read medication labels twice before administration. C. Document the administration of medications after all assigned clients have been medicated. D. Check the clients' allergy bands with each medication administration.

Correct Answer is D

Explanation

The correct answer is D. Checking the clients' allergy bands with each medication administration is a safety measure to prevent adverse drug reactions. According to the Healthline website, "Always ask patient about allergies, types of reactions, and severity of reactions" before giving any medication.

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A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has cirrhosis?

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Correct Answer is C

Explanation

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Correct Answer is D

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A nurse is reviewing laboratory findings for three clients.

Which of the following laboratory results should the nurse expect for a client who has cirrhosis?