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 ["A","C","E"]

Explanation

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.

A. Swab the throat for a rapid strep test. B. Provide a mask for the client to wear. C. Instruct client to stop taking the antibiotics. D. Apply a hypoallergenic cream to the rash.

Correct Answer is C

Explanation

Choice A reason: Swabbing the throat for a rapid strep test is not a priority action that the nurse should implement, because it is not relevant to the client's current condition. A rapid strep test is a diagnostic tool that can detect the presence of Streptococcus bacteria in the throat, which can cause strep throat, a common bacterial infection. However, the client has already been diagnosed with strep throat and has been taking antibiotics for three days, so the test result may not be accurate or useful.

Choice B reason: Providing a mask for the client to wear is not a necessary action that the nurse should implement, because it is not related to the client's problem. A mask is a protective device that can prevent the transmission of respiratory infections, such as COVID-19, influenza, or tuberculosis, by blocking the droplets or aerosols that contain the pathogens. However, the client's symptoms are not caused by a respiratory infection, but by an allergic reaction to the antibiotics, which is not contagious.

Choice C reason: Instructing the client to stop taking the antibiotics is the most important action that the nurse should implement, because it can prevent further exposure to the allergen and reduce the severity of the reaction. The client's symptoms, such as rash, wheezing, and tachycardia, indicate that the client is having an allergic reaction to the antibiotics, which can be a serious and potentially life-threatening condition, especially if it progresses to anaphylaxis, a severe systemic reaction that can cause shock, airway obstruction, and organ failure. The nurse should instruct the client to stop taking the antibiotics immediately and notify the doctor.

Choice D reason: Applying a hypoallergenic cream to the rash is not a sufficient action that the nurse should implement, because it can only provide temporary relief and not address the underlying cause of the rash. A hypoallergenic cream is a topical product that can moisturize, soothe, and protect the skin, and it does not contain any ingredients that can cause allergic reactions. However, the rash is not caused by a skin irritant, but by a systemic reaction to the antibiotics, which requires more than a cream to treat.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","E"]

Explanation

A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?

Correct Answer is C

Explanation

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