Nokea
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a client with liver cirrhosis
Item 1 of 1
Nurses' Note
57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.
Vital Signs
• Oral Temperature 101 o F (38.3o C)
• Heart rate 94/minute
• Respirations 24/minute
• Blood pressure 104/68 mm Hg
• Oxygen saturation 95% on room air
Medical History
• Hepatitis C
• Liver cirrhosis
• Substance use disorder
• Hyperlipidemia
Which assessment findings require follow-up? Select all that apply.
Correct Answer: B,D,E
Rationale: Labored breathing (B), elevated respiratory rate (D), and fever (E) indicate potential complications like infection or respiratory compromise in liver cirrhosis, requiring urgent follow-up. Jaundice and yellow sclera (A, F) are expected, and hypoactive bowel sounds (C) are less urgent.