The nurse overseeing care in the intensive care unit (ICU) reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?

The client admitted with malignant hypertension

The client admitted following a stroke

The client admitted with acute kidney injury

The client admitted following a myocardial infarction (MI)

Answer and Explanation

The Correct Answer is D

A. Malignant hypertension poses risks for other conditions but is not the primary risk factor for cardiogenic shock.
B. A stroke does not directly lead to cardiogenic shock, though it may have other significant complications.
C. Acute kidney injury affects renal function but is not the primary risk for cardiogenic shock.
D. A myocardial infarction (MI) can impair the heart's pumping ability, leading to cardiogenic shock. This is due to the damage to heart muscle that can severely impact cardiac output and blood pressure.

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Correct Answer is C

Explanation

A. Restricting sodium intake is essential in managing ascites and edema in cirrhosis, but it does not directly reduce ammonia levels. Sodium restriction is more related to fluid management rather than ammonia reduction.
B. Administering vitamin K may be necessary for correcting coagulation issues in liver disease, but it does not address the elevated ammonia levels causing encephalopathy.
C. Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms. Therefore, reducing dietary protein can help lower ammonia levels.
D. Administering diuretics is used to manage fluid retention and ascites in cirrhosis, but it does not directly impact ammonia levels. Diuretics are not the primary intervention for hepatic encephalopathy.

A. Open the client's airway using the jaw-thrust maneuver to provide oxygenation B. Check the client's cranial nerve function by assessing pupils equal, round, reactive to light, and accommodation (PERRLA) C. Place the client in a rigid cervical collar D. Evaluate the client for brain injury

Correct Answer is A

Explanation

A. The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
B. Checking cranial nerve function, including assessing pupils, is important for evaluating neurological status but is not the first action when the client is not breathing. Ensuring the airway is open and providing oxygenation is the priority.
C. While placing the client in a rigid cervical collar is important for stabilizing the spine and preventing further injury, it should be done after ensuring the airway is clear. The immediate concern is to address the client's non-breathing status.
D. Evaluating the client for brain injury is important for overall assessment but is secondary to addressing the immediate life threat of not breathing. Ensuring the airway is open and then stabilizing the spine is the priority.

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The nurse overseeing care in the intensive care unit (ICU) reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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