Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?
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Solution
Altered level of consciousness
Option B: Changes in behavior and level of consciousness are the first signs of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:
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Solution
Impaired clotting mechanism
Option A: Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
Which laboratory test indicates liver cirrhosis?
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Solution
Elevated serum aminotransferase
Option D: Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.
Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?
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Solution
Respiratory failure
Option C: The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure.
Options A and B: Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first.
Option D: Rheumatoid arthritis doesn’t manifest these signs.
Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents which of the following conditions?
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Solution
Respiratory acidosis
Option C: Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis.
Options B and D: The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities.
Option A: If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.
Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?
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Solution
80 mm Hg
Option D: A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.
The term “pink puffer” refers to the female client with which of the following conditions?
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Solution
Emphysema
Option D: Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.”
Option A: Clients with ARDS are usually acutely short of breath.
Option B: Clients with asthma don’t have any particular characteristics.
Option C: Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
The term “blue bloater” refers to a male client which of the following conditions?
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Solution
Chronic obstructive bronchitis
Option C: Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis.
Option A: Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen.
Option B: Clients with asthma don’t exhibit characteristics of chronic disease.
Option D: Clients with emphysema appear pink and cachectic.
During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is:
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Solution
Immediately discontinue the infusion
Option C: Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.
Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse-in-charge should:
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Solution
Apply viscous Lidocaine to oral ulcers as needed.
Option B: Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care.
Options A, C, and D: When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.