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 C
Explanation
Choice A reason: Bradycardia, which is a slower than normal heart rate, is not a common finding associated with renal calculi. Renal calculi, or kidney stones, typically cause symptoms related to the urinary system rather than directly affecting the heart rate.
Choice B reason: Bradypnea, or abnormally slow breathing, is also not a typical symptom of renal calculi. Patients with kidney stones may experience changes in urination patterns, such as frequency or urgency, but not typically changes in respiratory rate.
Choice C reason: Severe pain is indeed the most common symptom associated with renal calculi. This pain, known as renal colic, is often sudden in onset, very severe, and may radiate from the back down to the lower abdomen or groin. The pain is caused by the stone moving into the ureter and causing a blockage, which leads to increased pressure and stretching of the kidney or ureter. Renal calculi can cause a range of symptoms, with severe pain being the most prominent and often the first symptom that leads individuals to seek medical care. The pain is typically very intense and can be accompanied by other symptoms such as nausea, vomiting, and hematuria (blood in the urine).
Choice D reason: Nocturia, or frequent urination at night, can be a symptom of renal calculi, especially if the stones affect the bladder or cause urinary tract infections. However, the most characteristic symptom of renal calculi is severe pain, not necessarily nocturia.
Correct Answer is A
Explanation
Choice A reason:Pain that is relieved by food intake is a classic symptom of duodenal ulcers, as eating can neutralize stomach acid temporarily, providing relief.
Choice B reason:Pain radiating down the right arm is not a typical symptom of a duodenal ulcer; it is more commonly associated with cardiac issues.
Choice C reason:Nausea and vomiting can be associated with duodenal ulcers, but they are not as specific as pain relief by food intake.
Choice D reason:Weight loss can occur with duodenal ulcers due to pain and eating avoidance, but the key symptom that relates directly to the ulcer is pain relief after food intake.
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