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

Choice A rationale:

Elevated amylase is not typically associated with cirrhosis. Amylase is an enzyme produced by the pancreas and salivary glands, and elevated levels are more commonly associated with pancreatic disorders or acute pancreatitis.

Choice B rationale:

Decreased bilirubin is not an expected laboratory finding in cirrhosis. Cirrhosis often leads to impaired liver function, which can result in elevated bilirubin levels, causing jaundice.

Choice C rationale:

Elevated lipase is not a characteristic laboratory finding in cirrhosis. Lipase is an enzyme produced by the pancreas, and elevated levels are more often seen in pancreatic disorders or acute pancreatitis.

Choice D rationale:

The correct choice is D. Elevated ammonia levels are commonly associated with cirrhosis. In cirrhosis, the damaged liver is unable to effectively metabolize ammonia, leading to its accumulation in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a neurological complication often seen in cirrhotic patients.

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Correct Answer is B

Explanation

Choice A rationale:

The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.

Choice B rationale:

Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.

Choice C rationale:

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.

Choice D rationale:

Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.

A. "What makes you think the staff is following you?” B. "The psychiatric staff is not FBI. They are here to help you.” C. "Why do you feel the staff is the FBI?” D. "This must be very frightening for you. Let's talk more about it.”

Correct Answer is D

Explanation

Choice A rationale:

Asking, "What makes you think the staff is following you?" is a confrontational approach and may not be helpful in building rapport or addressing the client's paranoid beliefs. It can come across as dismissive and may exacerbate the client's anxiety.

Choice B rationale:

Telling the client, "The psychiatric staff is not FBI. They are here to help you," is a straightforward response but may not effectively address the client's concerns or build rapport. It does not acknowledge the client's feelings and may not be well-received.

Choice C rationale:

Asking, "Why do you feel the staff is the FBI?" is a more open-ended and therapeutic approach. It encourages the client to express their thoughts and feelings, providing an opportunity for the nurse to better understand the client's perspective.

Choice D rationale:

Saying, "This must be very frightening for you. Let's talk more about it," is the most empathetic and client-centered response. It acknowledges the client's emotions and offers support. It also opens the door for further discussion and therapeutic communication, allowing the nurse to explore the client's fears and concerns in a non-confrontational manner.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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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?