An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

Clear, dark amber-colored urine.

Improved level of consciousness.

Prothrombin time within normal limits.

Decreased abdominal girth.

Answer and Explanation

The Correct Answer is D

Choice A reason: Clear, dark amber-colored urine is not an assessment finding that indicates progress toward the desired effect of this treatment plan, because it may suggest dehydration, which can worsen the client's condition. The client with cirrhosis and hepatic failure may have fluid retention, electrolyte imbalance, and renal impairment, which can affect the urine output, color, and concentration. The nurse should monitor the client's fluid intake and output, urine specific gravity, and serum creatinine and blood urea nitrogen levels, and report any abnormalities to the doctor.

Choice B reason: Improved level of consciousness is an assessment finding that indicates progress toward the desired effect of this treatment plan, but it is not the most specific one. The client with cirrhosis and hepatic failure may have hepatic encephalopathy, which is a neuropsychiatric syndrome caused by the accumulation of ammonia and other toxins in the brain, due to the impaired liver function. This can cause changes in the level of consciousness, mental status, and behavior, such as confusion, lethargy, or coma. The nurse should assess the client's mental status using tools such as the Glasgow Coma Scale or the West Haven Criteria, and administer medications such as lactulose or rifaximin, as prescribed by the doctor, to reduce the ammonia levels. However, the level of consciousness can also be affected by other factors, such as hypoxia, hypoglycemia, or infection, and it is not directly related to the low sodium diet or the albumin infusions.

Choice C reason: Prothrombin time within normal limits is an assessment finding that indicates progress toward the desired effect of this treatment plan, but it is not the most specific one. The client with cirrhosis and hepatic failure may have coagulopathy, which is a bleeding disorder caused by the reduced synthesis of clotting factors, such as prothrombin, by the damaged liver. This can increase the risk of bleeding and hemorrhage, especially from the esophageal varices, which are dilated veins in the lower esophagus that can rupture due to portal hypertension, a complication of cirrhosis. The nurse should monitor the client's coagulation status using tests such as prothrombin time, international normalized ratio, and activated partial thromboplastin time, and administer blood products or vitamin K, as ordered by the doctor, to correct the coagulation defects. However, the prothrombin time can also be affected by other factors, such as anticoagulant therapy, vitamin K deficiency, or liver transplantation, and it is not directly related to the low sodium diet or the albumin infusions.

Choice D reason: Decreased abdominal girth is the most specific assessment finding that indicates progress toward the desired effect of this treatment plan, because it reflects the reduction of ascites, which is the accumulation of fluid in the peritoneal cavity, due to portal hypertension and hypoalbuminemia, common features of cirrhosis and hepatic failure. The low sodium diet and the albumin infusions are interventions that can help to decrease the fluid retention and increase the oncotic pressure, which can draw the fluid back into the blood vessels and reduce the ascites. The nurse should measure the client's abdominal girth daily, using a tape measure at the level of the umbilicus, and record the results. The nurse should also monitor the client's weight, edema, and abdominal discomfort, and report any signs of spontaneous bacterial peritonitis, such as fever, abdominal pain, or leukocytosis, to the doctor.

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Correct Answer is B

Explanation

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

A. Teach the client relaxation techniques. B. Determine the client’s food preferences. C. Maintain a patent intravenous site. D. Keep room temperature cool.

Correct Answer is C

Explanation

Choice A reason: Teaching the client relaxation techniques is a helpful action that the nurse can implement, but it is not the most important one. Relaxation techniques, such as deep breathing, meditation, or guided imagery, can help the client cope with stress, anxiety, and agitation, which are common symptoms of Grave’s disease, a condition that causes hyperthyroidism and overactivity of the thyroid gland. However, relaxation techniques alone cannot address the client’s physical needs, such as hydration, nutrition, and electrolyte balance, which are more urgent and critical.

Choice B reason: Determining the client’s food preferences is a considerate action that the nurse can implement, but it is not the most important one. Food preferences, such as taste, texture, temperature, and variety, can affect the client’s appetite and willingness to eat, which are important factors for maintaining adequate nutrition and weight. However, food preferences may not be the main reason for the client’s refusal to eat, and they may not be enough to overcome the client’s metabolic demands, which are increased by Grave’s disease.

Choice C reason: Maintaining a patent intravenous site is the most important action that the nurse should implement, given the client’s situation. A patent intravenous site can allow the nurse to administer fluids, electrolytes, medications, and nutrients to the client, who is at risk of dehydration, malnutrition, and complications from Grave’s disease, such as thyroid storm, cardiac arrhythmias, and infection. The nurse should monitor the client’s vital signs, fluid intake and output, blood glucose, and thyroid function tests, and adjust the intravenous therapy accordingly.

Choice D reason: Keeping room temperature cool is a supportive action that the nurse can implement, but it is not the most important one. Room temperature can affect the client’s comfort and thermoregulation, which are impaired by Grave’s disease, which causes heat intolerance, sweating, and fever. However, room temperature alone cannot correct the underlying hormonal imbalance or the systemic effects of Grave’s disease, and it may not be sufficient to prevent the client from becoming restless and agitated.

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An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

Nursing Test Bank

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