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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not recommend placing the diaper over the strap of the Pavlik harness. Placing the diaper over the strap can cause discomfort and may interfere with the proper function of the harness, which is designed to maintain hip joint alignment in infants with developmental hip dysplasia.
Choice B rationale:
The Pavlik harness is typically worn continuously, including during sleep. It should not be removed for sleeping each night because consistent use is essential for its effectiveness in promoting hip joint development.
Choice C rationale:
Applying lotion under the straps of the harness is not recommended. Lotions or creams can create friction and moisture, which may lead to skin irritation or discomfort for the infant. It's best to follow the healthcare provider's instructions regarding the care and maintenance of the harness.
Choice D rationale:
The correct choice is D. The nurse should include the statement that "The harness can promote hip joint development" in the teaching. This is because the Pavlik harness is used to treat developmental hip dysplasia by maintaining the hip joint in a stable position, allowing for proper development. It is important for parents to understand the purpose and benefits of the harness in order to ensure compliance and effectiveness of the treatment.
Correct Answer is C
Explanation
Choice A rationale:
Inquiring about a family history of suicide is relevant but not the priority when a client is actively expressing suicidal ideations. Assessing the client's immediate risk and intent is more critical.
Choice B rationale:
Understanding the stresses in the client's life is important, but asking about a plan for self-harm takes precedence in assessing the client's immediate danger.
Choice C rationale:
This question directly addresses the client's intent and plan for self-harm. Identifying a plan is crucial in assessing the level of risk and determining the appropriate intervention.
Choice D rationale:
While having someone to discuss feelings with is important, it is not the primary concern when a client is expressing suicidal ideations. Assessing the client's immediate risk and plan for self-harm should come first.
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