A patient is in the late stages of liver failure with cirrhosis and progressive, irreversible damage. Knowing this, the nurse explains to the family that:
1. Liver transplantation is the only feasible treatment.
2. Abstinence from alcohol may decrease further liver cell injury and improve portal hypertension.
3. The liver is the only organ affected so that the patient and family need not worry about other body systems.
4. If the patient does not have any variceal hemorrhages he will probably live for years.
2
Rationale 1: Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful.
Rationale 2: In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension.
Rationale 3: All body systems are affected with hepatic dysfunction. It is a multisystem dysfunction—fluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal.
Rationale 4: Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient does not develop varices, this patient will not survive for years.
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Upon admission for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor
What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping
A client is requesting a prescription for tadalafil (Cialis). What priority assessment question should the nurse ask this client?
1. "Do you have any sexually transmitted diseases?" 2. "Do you take nitroglycerin?" 3. "Have you received a diagnosis of diabetes?" 4. "Do you take medication for high blood pressure?"