What will the nurse most likely find on assessment of a patient with acute liver failure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Jaundice
2. Sudden severe nose bleed
3. Ascites
4. Peripheral edema
5. Asterixis
1,2
Rationale 1: Severe acute liver injury can lead to impaired elimination of bilirubin leading to jaundice, which may appear immediately before or soon after presentation.
Rationale 2: Acute bleeding is an indication of coagulopathy, which is seen in acute liver failure.
Rationale 3: Ascites is a manifestation of chronic liver failure.
Rationale 4: Peripheral edema is a manifestation of chronic liver failure.
Rationale 5: Asterixis is a manifestation of chronic liver failure.
You might also like to view...
The nurse often assists in the process of obtaining informed consent from the client for treatment and/or procedures. Who has the responsibility of providing information to the client so he can give informed consent?
a. Social worker b. Nurse c. Physician d. Facility's legal representative
An advantage of both the total patient care and the case method of care delivery is:
a. cost c. continuum of care b. same patients d. consistency of care
You are caring for a newborn who has a nursing diagnosis of "Risk for hypothermia related to prematurity, abnormal disorders at birth, and/or exposure to cool environments"
Your plan of care should include which of the following? (Select all that apply.) a. Provide a neutral thermal environment. b. Prevent conditions that precipitate cold stress. c. Teach mother proper breastfeeding technique. d. Teach the breastfeeding mother proper care of her nipples. e. Identify the infant at risk for potential or actual temperature instability. f. Teach parents how to maintain the infant's temperature.
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time
a. Allow her to wear her underpants. b. Discuss with her mother why this is important to the child. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy.