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. Check blood glucose daily B. Monitor for dark color of urine C. Follow low carbohydrate diet D. Change positions slowly

Correct Answer is D

Explanation

A) Checking blood glucose daily is not directly relevant unless the client also has diabetes.

B) While this can indicate other health issues, it is not specific post-paracentesis advice.
C) A low carbohydrate diet is not typically related to post-paracentesis care unless specified by the healthcare provider for other underlying conditions.
D) Change positions slowly is important to prevent postural hypotension and falls after fluid removal during paracentesis. It prevent dizziness or lightheadedness due to fluid shifts or blood pressure changes after the procedure.

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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

The nurse is preparing discharge teaching for a client who has had a paracentesis. What information should be included in the education session?

Correct Answer is D

Explanation

The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

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The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?

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The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?