The nurse is caring for a client who has been admitted after an acetaminophen overdose. Which of the nurse's assessment findings suggest liver damage? (Select all that apply.)
The client's skin and eyes are visibly jaundiced.
The client's AST and ALT levels are elevated.
The client's temperature is 102.5° F (39.2° C).
The client has an elevated red blood cell count.
The client's eyes are sensitive to light.
Correct Answer : A,B
A. The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.
B. The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.
C. The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.
D. The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.
E. The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While resting heart rate and blood pressure are important for overall cardiovascular health, they do not specifically assess the effectiveness of atorvastatin in lowering lipid levels.
B. Reviewing laboratory blood work results, particularly lipid panels, is essential to determine the therapeutic effect of atorvastatin, as it directly measures changes in cholesterol levels (such as LDL and total cholesterol).
C. Assessing exercise tolerance and activities of daily living can provide insight into overall health and well-being but does not specifically evaluate the impact of atorvastatin on lipid levels.
D. A focused cardiac assessment is beneficial for understanding cardiovascular health but is not specific for measuring the effectiveness of lipid-lowering therapy with atorvastatin.
Correct Answer is ["A","B","C"]
Explanation
A. Auscultating bowel sounds is important because anticholinergic agents can decrease gastrointestinal motility, leading to reduced bowel sounds and potential constipation.
B. Monitoring urine output is crucial as anticholinergics can cause urinary retention, and assessing output helps identify any adverse effects on bladder function.
C. Monitoring heart rate is necessary since anticholinergic agents can cause tachycardia as a side effect, making it important to assess the client’s cardiovascular status.
D. Administering an antidiarrheal agent is not typically indicated, as anticholinergic agents often cause constipation rather than diarrhea.
E. Assessing deep tendon reflexes is not directly relevant to the effects of anticholinergic medications and is not typically prioritized in this context.
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