The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
a. The patient complains of right upper-quadrant pain with palpation.
b. The patient's hands flap back and forth when the arms are extended.
c. The patient has ascites and a 2-kg weight gain from the previous day.
d. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
b. The patient's hands flap back and forth when the arms are extended.
Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.
You might also like to view...
A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a bat at baseball practice. The child was not wearing a helmet
The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: 1. A sign that this child has a spinal cord injury. 2. A sign of increased intracranial pressure. 3. Typical for a sleeping child at this age. 4. A sign that the child's condition is improving.
A 70-year-old woman who experiences frequent leg pain due to sciatica tells her nurse, "I've been hearing a lot about how well acupuncture works for chronic pain and I think I might give it a try."
How can the nurse best respond to the woman's statement? A) "That sounds like an excellent idea and I'd encourage you to go ahead with it.". B) "Before you begin the treatment it's likely best to get your physician's permission.". C) "A lot of these types of treatments are unproven and even dangerous, so be very careful.". D) "Perhaps I can tell you about the risks, benefits, and limitations of acupuncture first.".
The nurse explains that the older adults account for a large percentage of the total deaths resulting from falls. This percentage is:
1. 13%. 2. 27%. 3. 40%. 4. 72%.
A nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient's primary health-care provider. This type of communication is called
1. Upward. 2. Bilateral. 3. Horizontal. 4. Downward.