A client with liver cirrhosis complains of severe itching. Which term should the nurse use to document this symptom?
Jaundice
Pruritus
Hematemesis
Ascites
The Correct Answer is B
Jaundice refers to the yellowing of the skin and eyes and is caused by the accumulation of bilirubin in the blood. While jaundice can be associated with liver cirrhosis, it does not describe the symptom of severe itching.
Pruritus refers to severe itching of the skin, which can occur in clients with liver cirrhosis due to the buildup of bile acids in the blood and skin. Elevated levels of bile acids can irritate the skin, leading to itching.
Hematemesis refers to vomiting of blood and is not related to the symptom of severe itching.
Ascites is the accumulation of fluid in the abdominal cavity and is not related to the symptom of severe itching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not typically associated with difficulty sleeping or shortness of breath.
B) Portal hypertension, a common complication of liver cirrhosis, can lead to the development of ascites and esophageal varices, among other manifestations. It is not the likely cause of the client's difficulty sleeping and shortness of breath.
C) Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease and is not associated with difficulty sleeping or shortness of breath.
D) Hepatopulmonary syndrome is a complication of liver cirrhosis characterized by the development of pulmonary vascular dilation and arteriovenous shunting. This results in impaired oxygenation of blood, leading to difficulty breathing (dyspnea), especially while lying down (orthopnea). Clients with hepatopulmonary syndrome often experience frequent awakenings due to shortness of breath during sleep.
Correct Answer is D
Explanation
A) While adequate protein intake is necessary for overall health, excessive protein intake may worsen hepatic encephalopathy in some clients with liver cirrhosis. The priority for this client is to avoid alcohol consumption, not necessarily to increase protein intake.
B) Clients with liver cirrhosis and associated ascites should be on a low-sodium diet to reduce fluid retention and prevent complications related to ascites.
C) Limiting fluid intake is not a standard recommendation for clients with liver cirrhosis. Instead, clients with ascites may be advised to follow a low-sodium diet and, if necessary, restrict fluid intake under the guidance of their healthcare provider.
D) For a client with liver cirrhosis, the most crucial dietary modification is to restrict alcohol consumption completely. Alcohol is a major contributing factor to liver damage and can exacerbate cirrhosis. Abstinence from alcohol is essential to prevent further liver injury and improve the client's overall prognosis.
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