The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which of the following clinical findings would indicate that the patient's condition is deteriorating?
1. change in level of consciousness
2. tachycardia
3. hypotension
4. respiratory rate of 22 per minute and regular
1
Rationale: In acute hepatic dysfunction caused by fulminant hepatic failure manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is having deterioration would be a change in level of consciousness. Other classic signs seen in a patient with acute hepatic dysfunction include Cushing's triad with the symptoms of bradycardia, hypertension, and irregular respirations. The symptoms of tachycardia, hypotension, and respiratory rate of 22 would not be indications that the patient's status is deteriorating.
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