A client with end-stage cirrhosis and gastrointestinal bleeding becomes combative and confused. What complication of cirrhosis may this client be experiencing?
A. Ascites
B. Coagulation defects
C. Transient ischemic attack
D. Portal-systemic encephalopathy
D
Although the client may already have ascites and coagulation defects, a client with end-stage cirrhosis who develops a GI bleed is at increased risk of portal-systemic encephalopathy, because this causes an increased protein load in the intestines.
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The nurse manager is reviewing an occurrence report written after a client fall. For which personal factors should the manager consider as contributing to this occurrence? (Select all that apply.)
1. Patient consumed 75% of last meal 2. Patient's team leader a new graduate 3. Unlicensed assistive personnel assigned working a double shift 4. "Ambulate with assistance" not written on the Kardex care plan 5. Patient being discharged to a skilled nursing facility the next day
A client is found to need corrective lenses for myopia. Which of the following explanations would the nurse provide to this client?
1. "Your glasses will help you to see objects in the distance.". 2. "Your glasses will help you to see objects that are very close to you.". 3. "Your glasses will help you to improve your eyes' ability to focus and reduce your blurred vision.". 4. "Your age has made it more difficult to read items that are at close range. Your new glasses will help.".
A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first?
a. Remove bedding from around the adaptor opening. b. Listen to lung sounds and obtain a respiratory rate. c. Call respiratory therapy to check oxygen saturation. d. Notify the provider or Rapid Response Team immediately.
An 84-year-old woman is admitted to the hospital after a fall during which she hit her head. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The patient reports tenderness on palpation and movement
What would be an appropriate nursing diagnosis for this patient? A) Impaired skin integrity related to bed rest B) Impaired range of motion related to injury C) Immobility related to bed rest D) Neck pain related to possible neck injury