A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?
a. Asterixis and lethargy
b. Jaundiced sclera and skin
c. Elevated total bilirubin level
d. Liver 3 cm below costal margin
a. Asterixis and lethargy
The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.
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