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Difficulty: MediumEstablishing Priorities

During the initial admission assessment of a client with hepatic cirrhosis, the nurse identifies several clinical findings. Which of the following findings require immediate notification to the healthcare provider? Select all that apply.

  1. Emesis of 200 mL of bright red bloodAnswer
  2. Apical pulse of 118 beats per minute with a blood pressure of 88/54 mm HgAnswer
  3. C
    Noticeable yellowing of the sclerae and oral mucosa
  4. Sudden onset of spatial disorientation and inability to state the current yearAnswer
  5. E
    Multiple spider angiomas noted on the upper chest and shoulders

Answer

The findings requiring immediate notification are the emesis of bright red blood, the vital signs indicating potential shock (elevated heart rate with low blood pressure), and the sudden onset of spatial disorientation.
The correct selections represent acute, unexpected, and potentially life-threatening complications of cirrhosis. Hematemesis and hypotensive tachycardia indicate active bleeding and hemodynamic shock (Circulation priority). Acute disorientation indicates worsening hepatic encephalopathy, which is a critical neurological emergency.

Step-by-Step Solution

1
Analyze each clinical finding to determine if it represents an acute, life-threatening complication or an expected, chronic manifestation of hepatic cirrhosis.
Identified acute versus chronic clinical manifestations.
Prioritization requires distinguishing between stable baseline abnormalities and unstable, emergency situations.
2
Evaluate the emesis of bright red blood and the hypotensive, tachycardic vital signs.
Determined these are indicators of active hemorrhage and hemodynamic instability.
Airway and Circulation (ABC) compromises are the highest priority and require immediate medical intervention.
3
Evaluate the sudden spatial disorientation.
Determined this is an acute neurological decline indicating hepatic encephalopathy.
Acute changes in mental status are medical emergencies that can rapidly progress to airway compromise or coma.
4
Evaluate the scleral icterus (yellowing) and spider angiomas.
Determined these are expected, chronic disease manifestations.
Expected findings, even when significantly abnormal from a healthy baseline, do not require immediate emergency notification.

Key Concept

In clinical prioritization, acute, unexpected, and life-threatening complications (such as active hemorrhage, shock, and acute neurological decline) must be addressed before chronic, expected disease manifestations.
Estimated Time:1m 30s
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Establishing Priorities

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