Walkthrough: Physiological Adaptation Q19 – NCLEX-RN®

00:00 The nurse is caring for clients diagnosed with liver cirrhosis. Which client does the nurse need to see first? This is another one of those prioritization questions. Think of it like a triage question. They're trying to test if you recognize who's in the most danger. Remember, everyone deserves to be seen, everyone will be seen, they're just wanting to test if you can triage or recognize who's in the most danger and requires the most immediate intervention. Now, that doesn't mean that any one of these patients are going to die. It just means compare to the other patients who should be your first priority. Alright, you've got the strategy, you've got your scratch paper, you know how to put the numbers down, and compare each patient to the others. So pick whatever patient you want to be your baseline, start with that patient, and then compare them to another patient, decide who is the biggest priority, eliminate the other one, compare your remaining answer to the other answer, and so on until you end up with your best answer. Alright, pause the button, pause the video, then come back when you're done doing the work, and we'll do a walk through. Hi, welcome back, let me just say you're doing a good job.

01:20 Hang in there. I know it's hard but it is going to pay off for you, I promise. So, who do I see first for these clients diagnosed with liver cirrhosis? Okay, let me start number 2. A client with a pain level of 8, whoah ouch, with suspected liver cancer.

01:38 Okay, now they are not very comfortable, we know they've got liver cancer. Wow, that's a tough diagnosis, but now my job is to compare them to somebody else.

01:48 Let's go to number 1 since it's right there. So, would it be a bigger priority to see number 2 or a client with ascites who has a poor appetite? Now, I mean I recognize why they have ascites because they have cirrhosis. I understand why they have a poor appetite because their liver is so messed up, but they would not be a higher priority over the client who has the pain with a level of 8 and has suspected liver cancer. So number 1, I'm going to cross you off and that's my rationale. Now, let's compare number 2 to number 3. A client with jaundice, that's not normal; 3+ pitting edema, that's not normal; and elevated LFTs, liver function tests. Okay, they are not doing well and they're really showing some symptoms like they've got fluid going everywhere, they've got edema, so actually I'm not sure. I'm not sure if I would see doing 2 and 3. Let me look at 4 because sometimes that happens. A client with tarry stools and lightheadedness. Well, what does tarry stools have to do with someone who has liver problems? Right? Why is that a thing? Well, what are the signs of tarry stools? Like what causes tarry stools? Ahh, when someone has that kind of unusual bowel movement, that means there is bleeding somewhere.

03:15 Now if I have somebody with cirrhosis, I know they have a high risk for esophageal varices, portal hypertension. So, now you've got my attention. Tarry stools means there could be some internal bleeding going on in that GI tract. They have tarry stools and they're lightheaded might mean they are having some fairly significant bleeding in there. This could be some heavy bleeding that we haven't seen come all the way out yet. So this, out of all the other ones, is going to be the patient I see first. Now, why? Why is tarry stools and lightheadedness a bigger deal than the pain? Well, pain is significant, pain is a problem and deserves to be treated, pain is what the patient reports it as no matter what you think you observe.

04:01 However, the pain is not going to put your patient in danger. It's uncomfortable and we are empathetic with it but it's not going to kill your patient. Number 4, if an esophageal varices is going to burst, that is a life-threatening problem. So that's why number 2 is not a bigger deal. Now number 3, jaundice, that means wow could be your liver isn't working well because your bilirubin level is going up, you look like a pumpkin. 3+ pitting edema, whoah, that's uncomfortable and a sign that things are not well and we know that your liver function tests are not doing well either. That means the liver isn't functioning but you are not in imminent danger and number 4 might be. We don't know for sure that they are, but compared to the others, number 4 is the client that should be seen first because of the risk of esophageal varices bursting and the patient being in a life-threatening situation.

04:57 Okay, not a pretty topic in this question. Right? And if you ever cared for a patient who has a GI bleed, whoah, there is an odor that goes along with that that you will never forget. When I would step off the elevator at night to go to work it would be like "Yes, we clearly have a GI bleed in one of the units." It's really something that is imprinted on your nose when you're done taking care of that patient. So keep in mind it's all relative. Right? That doesn't mean one of these patients is going to die but it means of these 4 who is the one who is at the highest risk to have a bad outcome or to be unsafe. So, don't get frustrated if you're feeling like "Ahh, I keep missing this." It's okay. I would expect you to because you're learning. Just make sure you're learning everything you can for me to question, taking the time to pause and reflect, and how you work through that question, what strategy worked well for you, what strategy did you cut corners and maybe it didn't work for you. So find the best strategy that's consistent for you and that works. And keep going.

06:00 Join us for another question as soon as you feel ready.