As a result of cirrhosis of the liver, the patient's condition deteriorates and he slips into a hepatic coma. The nurse would anticipate increasing levels of:
a. Amylase
b. Ammonia
c. Thrombocytes
d. Bilirubin
B
Hepatic encephalopathy is a type of brain damage caused by liver disease and consequent ammonia intoxication. Ammonia is the breakdown product of protein.
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The nurse is caring for a 10-year-old girl with burns covering two-thirds of her body caused by a home fire. Which of the following are chief nursing concerns in treating this client? Select all answers that apply
A) Combating shock B) Repair of damage C) Alleviating pain D) Applying pressure garments E) Prevention of contractures F) Restoration of fluid and electrolyte balance
Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention?
a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."
The patient with Alzheimer's disease (AD) has been on donepezil (Aricept) for several weeks. In which situation would the nurse suspect an overdose?
a. The patient hungrily eats meals and often searches for snacks between meals. b. The nurse assesses a radial pulse rate of 92 beats/min. c. The patient's blood pressure is elevated after periods of exertion. d. The patient fails to grasp a glass tightly enough to prevent dropping it.
A client with GAD states, "I have learned that the best thing I can do is to forget my worries." How would the nurse evaluate this statement?
a. The client is developing insight. b. The client's coping skills have improved. c. The client needs encouragement to verbalize feelings. d. The client's treatment has been successful.