A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Risk for bleeding

Risk for activity intolerance

Risk for impaired nutrition: less than body requirements

Risk for impaired skin integrity

Answer and Explanation

The Correct Answer is A

A)   Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.

B)   While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C)   Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D)   Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.

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Correct Answer is D

Explanation

A) Breath with fecal odor could indicate hepatic encephalopathy, for which lactulose is indicated.
B) Increasing confusion is a symptom of hepatic encephalopathy suggests a need for lactulose.
C) Elevated ammonia levels indicate hepatic encephalopathy hence the need for lactulose.
D) If the client already has diarrhea, additional doses of lactulose (which acts as a laxative) could exacerbate this condition and might need to be adjusted or halted based on clinical judgment.

A. Monitor I&O B. Check blood pressure C. Assess pain level D. Measure oxygen saturation

Correct Answer is B

Explanation

A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.

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A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?

Correct Answer is D

Explanation

While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?

Correct Answer is B

Explanation

The nurse is preparing a community presentation about hepatitis B virus (HBV). Which information should be included in the teaching session?

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A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

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