The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
Evaluate for asterixis
Palpate for peripheral edema
Evaluate for decreased level of consciousness
Inspect for petechiae
The Correct Answer is B
Choice A reason: Asterixis, also known as “liver flap,” is a type of tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers. It is associated with hepatic encephalopathy, a condition that can occur with severe liver disease, but it is not a direct indicator of low albumin levels.
Choice B reason: Peripheral edema is a common clinical finding in patients with hypoalbuminemia, which is a low level of albumin in the blood. When albumin levels are low, fluid from the bloodstream can leak into body tissues, causing swelling, especially in the lower limbs. When assessing a client with liver disease and low albumin levels, palpating for peripheral edema would be the most relevant nursing assessment, as it directly correlates with the effects of hypoalbuminemia on fluid balance in the body. Albumin is a protein made by the liver that helps keep fluid in your blood vessels and plays a role in transporting substances throughout your body. Low levels of albumin can lead to fluid leaking out of blood vessels into tissues, causing swelling or edema.
Choice C reason: Decreased level of consciousness can be a sign of various conditions, including hepatic encephalopathy or other complications of liver disease, but it is not specifically indicative of low albumin levels.
Choice D reason: Petechiae are small red or purple spots caused by bleeding into the skin and may be associated with various conditions, including liver disease, but they are not a specific sign of low albumin levels.
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Related Questions
Correct Answer is D
Explanation
Choice A. An embolic stroke is caused by an embolus, often a blood clot, that travels to the brain from another part of the body. It does not typically present with a sudden, severe headache.
Choice B. A thrombotic stroke occurs when a blood clot forms inside one of the brain's arteries. While it can cause a headache, it is not usually characterized by a sudden, severe headache.
Choice C. A transient ischemic attack (TIA) is often called a mini-stroke and symptoms are temporary. A sudden, severe headache is more indicative of a hemorrhagic stroke.
Choice D. A hemorrhagic stroke, which involves bleeding within the brain, is most likely to cause a sudden, severe headache, and can lead to seizures and changes in consciousness.
Correct Answer is C
Explanation
Choice A reason: Metabolic alkalosis would present with an elevated pH and HCO3, which is not the case here.
Choice B reason: Respiratory alkalosis would present with an elevated pH and a decreased PaCO2, which is not the case here.
Choice C reason: Metabolic acidosis is indicated by a decreased pH and HCO3, which aligns with the ABG findings provided.
Choice D reason: Respiratory acidosis would present with a decreased pH and an elevated PaCO2, which is not the case here.
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