the nurse is caring for a client with cirrhosis of the liver which laboratory result requires immediate intervention
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HESI RN

Community Health HESI 2023 Quizlet

1. The nurse is caring for a client with cirrhosis of the liver. Which laboratory result requires immediate intervention?

Correct answer: D

Rationale: The correct answer is D, the serum ammonia level of 180 mcg/dL. An elevated serum ammonia level indicates hepatic dysfunction and can lead to hepatic encephalopathy, which is a medical emergency requiring immediate intervention. Options A, B, and C are within normal ranges or slightly abnormal values for clients with cirrhosis and do not pose an immediate threat. Serum albumin levels may indicate malnutrition, prothrombin time may reflect liver synthetic function, and hemoglobin levels can be affected by various factors but do not require immediate intervention in this scenario.

2. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.

3. A nurse has started a group for senior citizens in a church setting. The group decides that their first project will be to begin a program for home-bound members. Which program outcome is the best measure of the project's effectiveness?

Correct answer: A

Rationale: The number of home-bound seniors visited is the best measure of the project's effectiveness as it directly reflects the reach and impact of the program. Choice B is incorrect as it does not directly relate to the effectiveness of the program for home-bound seniors. Choice C is irrelevant as the average annual income of home-bound members is not a direct measure of the program's effectiveness. Choice D, calls showing interest, is not as direct a measure as the actual visits to the home-bound seniors.

4. The nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which finding supports this diagnosis?

Correct answer: D

Rationale: The correct answer is D: Redness and warmth in the affected leg. These are classic signs of deep vein thrombosis (DVT) and support the diagnosis. Choice A, Positive Homan's sign, is an outdated and unreliable test for DVT, so it is not the best choice. Choice B, Unilateral leg swelling, can be seen in DVT but is less specific compared to redness and warmth. Choice C, Bilateral calf pain, is not a typical finding in DVT, as the pain in DVT is usually unilateral.

5. A community health nurse is working with a local organization to address food insecurity. Which action should the nurse prioritize?

Correct answer: C

Rationale: The correct answer is establishing a weekly meal program for those in need. This action prioritizes providing consistent and reliable access to food for individuals experiencing food insecurity. While organizing a food drive (Choice A) and partnering with local businesses to donate food (Choice D) are helpful, they may not offer a sustainable solution for ongoing food needs. Creating a community garden (Choice B) may promote self-sufficiency and access to fresh produce, but it may not address the immediate food needs of individuals who are food insecure. Therefore, establishing a weekly meal program is the most effective choice to ensure regular access to food for those in need.

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