Author Question: The nurse is assessing a patient with ascites caused by liver failure. Which finding would require ... (Read 79 times)

tiffannnnyyyyyy · **on:** Jun 25, 2018

The nurse is assessing a patient with ascites caused by liver failure. Which finding would require immediate follow-up by the nurse?

1. asterixis
2. jaundice
3. increased abdominal girth
4. dyspnea

Question 2

The nurse is caring for a patient with a Sengstaken-Blakemore tube. Which assessment finding should the nurse immediately report for follow-up?

1. left lower leg swollen and reddened
2. absent bowel sounds to lower-left quadrant
3. decreased level of consciousness
4. 3 cm darkened area on left heel

mmpiza · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 4
Dyspnea is the immediate priority for this patient. Asterixis or liver flap is a muscle tremor that interferes with the ability to maintain a fixed position of the extremities, causes involuntary jerking movements, and is an early sign of portal systemic encephalopathy. Jaundice is a chronic problem with liver failure and does not present an immediate threat to the patient. Increased abdominal girth is likely the result of ascites and may be contributing to the patient's shortness of breath. Although all of these symptoms should be reported to the primary healthcare provider, the nurse's immediate priority is the shortness of breath.

Answer to Question 2

Correct Answer: 3
The Sengstaken-Blakemore tube has two balloons, which are used to tamponade the esophageal bleeding. One balloon is in the stomach and the other is in the esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate hypoxia and is the priority for follow-up. A swollen and reddened lower leg may indicate a venous thrombus. Absent bowel sounds may indicate ileus. A darkened area on the left heel may indicate a pressure ulcer. While all of these are potentially serious problems, the possibility of hypoxia is the priority for follow-up.