The critical care nurse is caring for a patient with cirrhosis. What is an essential nursing function when caring for a patient with cirrhosis?
A) Monitoring the patient's oral intake
B) Monitoring the patient's support network
C) Monitoring the patient for signs of hypervolemia
D) Monitoring the patient's mental status
Ans: D
Feedback: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. An extensive neurologic evaluation is key to identify progression through the four stages of encephalopathy. The nurse would monitor the oral intake and watch for signs of hypervolemia, but they are not as essential as the patient's mental status because of the encephalopathy that goes with cirrhosis. Monitoring the support network is not essential at this time.
You might also like to view...
Order the six steps of The Wellness Recovery Action Plan(WRAP) Model as described by Copeland et al
1. ________ Daily Maintenance List 2. ________ Things Are Breaking Down or Getting Worse 3. ________ Crisis Planning 4. ________ Develop a Wellness Toolbox 5 _________ Early Warning Signs 6._________ Triggers
While teaching a health promotion class to a group of parents of children in a Head Start class,the nurse informs the parents that the most common preventable chronic infectious disease in U.S.children is
1. hepatitis A. 2. dental decay. 3. human immunodeficiency virus. 4. herpes.
The Active Potential Assessment Model (APAM) directs nursing assessment in which theory?
A) Modeling and Role-Modeling B) Systems Framework and Theory of Goal Attainment C) Adaptation Model D) Model of Nursing Based on Activities of Living
Attachment symbols are used in an ecomap to depict:
a. problems of all the family members b. the power of individual family members c. the chronological history of extended family relationships d. the degree of closeness in relationships