Unit 7 Bow-Tie Exam Question
A client presents to the emergency department via person vehicle.
Nursing Notes: Client spouse reports the client has become increasingly confused over the past few hours.
Client is experiencing increased work of breathing. Spider angiomas noted to the abdomen, which is
enlarged. Spouse reports the client drinks 5-6 beers each night after work.
Labs
Fecal occult blood
Hep. B Surface Antigen
Reference Range
Negative
Negative
Results
Positive
Negative
WBC
4,000-10,000
11,300
Amylase
Lipase
ALT
AST
Albumin
0-130
< 95
0-35
0-35
3.5-5.0
130
85
64
58
2.8
Vital SignsBP- 108/64
HR- 102
Temp.- 98.9 (37.2)
RR- 22
Potential Condition:
Cirrhosis
Pancreatitis
Cholecystitis
Hepatitis B
Actions to Take:
Administer interfron injections
Prepare the client for sclerotherapy
Restrict protein intake
Administer ordered antibiotics
Administer pancrelipase with meals/snacks.
Parameter to Monitor:
Daily sodium intake
Unprotected sexual contact
Prothrombin time
Stool color Glucose level every 4 hours