The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

Weight loss

Pedal edema

Flushed skin

Hematemesis

Answer and Explanation

The Correct Answer is B

A) Ascites, the accumulation of fluid in the abdominal cavity, typically presents with weight gain rather than weight loss.
B) Ascites often accompanies peripheral edema, particularly in the lower extremities.

C) Ascites is not typically associated with flushed skin; rather, it may lead to pallor due to anemia or jaundice due to liver dysfunction.
D) Ascites is not directly associated with vomiting blood; hematemesis may indicate complications such as esophageal varices, which can occur in advanced liver disease.

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Correct Answer is A

Explanation

A) Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B) The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C) This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D) While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.

A. Breath with fecal odor B. Increasing confusion C. Serum ammonia level 72 mcg/dL (15-45 mcg/dL) D. Diarrhea

Correct Answer is D

Explanation

A) Breath with fecal odor could indicate hepatic encephalopathy, for which lactulose is indicated.
B) Increasing confusion is a symptom of hepatic encephalopathy suggests a need for lactulose.
C) Elevated ammonia levels indicate hepatic encephalopathy hence the need for lactulose.
D) If the client already has diarrhea, additional doses of lactulose (which acts as a laxative) could exacerbate this condition and might need to be adjusted or halted based on clinical judgment.

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The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Correct Answer is A

Explanation

A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?

Correct Answer is D

Explanation

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When reviewing a client's health history, which information does the nurse identify as a risk factor for development of chronic pancreatitis?

The nurse notes these laboratory results for a client with cirrhosis: PT 20 seconds (11-12.5 sec) and serum ammonia 35 mcg/dL (15-45 mcg/dL). What action by the nurse would be a priority?

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