A client with liver cirrhosis is at risk of bleeding due to decreased synthesis of clotting factors. Which nursing intervention is essential in preventing bleeding episodes?

Encouraging frequent ambulation and leg exercises.

Applying cold packs to areas of potential bleeding.

Using a soft-bristle toothbrush for oral care.

Administering intramuscular injections cautiously.

Answer and Explanation

The Correct Answer is C

A) While ambulation and leg exercises are essential for maintaining overall health, they are not directly related to preventing bleeding episodes in clients with liver cirrhosis. The risk of bleeding in these clients is primarily related to clotting factor synthesis impairment.

B) Applying cold packs can help reduce swelling and inflammation but may not be the most appropriate intervention for preventing bleeding episodes in clients with liver cirrhosis. Cold packs may have limited effectiveness in addressing the underlying clotting factor deficiency.

C) Clients with liver cirrhosis may experience impaired clotting due to decreased synthesis of clotting factors by the liver. To prevent bleeding episodes, using a soft-bristle toothbrush for oral care is essential. A soft-bristle toothbrush is gentler on the gums and oral tissues, reducing the risk of causing trauma or bleeding during oral hygiene practices.

D) While it is important to administer intramuscular injections cautiously in clients with clotting disorders, this intervention is not the most essential for preventing bleeding episodes. Clients with liver cirrhosis are at risk of bleeding primarily due to the liver's decreased synthesis of clotting factors, not necessarily due to intramuscular injections.

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Correct Answer is C

Explanation

A) Iron supplements are not a priority intervention for a client with hepatic encephalopathy. In fact, administering iron supplements without proper indication can be harmful, as excessive iron can worsen liver damage in cirrhosis.

B) While monitoring fluid intake and output is important in managing various aspects of liver cirrhosis, it is not the essential intervention for hepatic encephalopathy. The priority in hepatic encephalopathy is to ensure seizure precautions and address the client's altered mental status.

C) Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis that can lead to altered mental status, confusion, and potential seizures. Implementing seizure precautions is essential in the care of this client to ensure their safety and prevent injury during any potential seizure activity. Seizure precautions may include padding the side rails of the bed, ensuring a clear and clutter-free environment, and providing close supervision to the client. In severe cases, the healthcare provider may prescribe antiepileptic medications to manage and prevent seizures.

D) Encouraging a high-protein diet is not appropriate for a client with hepatic encephalopathy. High-protein diets can exacerbate hepatic encephalopathy by increasing ammonia production in the intestines. Instead, the client should be prescribed a controlled-protein diet and, in some cases, given lactulose to help reduce ammonia levels.

A. Hepatocellular carcinoma B. Portal hypertension C. Hepatic encephalopathy D. Hepatopulmonary syndrome

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.

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A client with liver cirrhosis is at risk of bleeding due to decreased synthesis of clotting factors. Which nursing intervention is essential in preventing bleeding episodes?

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Naxlex Comprehensive Predictor Exams

A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

Correct Answer is C

Explanation

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?

Correct Answer is D

Explanation

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A client with liver cirrhosis is experiencing episodes of hepatic encephalopathy. Which medication should the nurse anticipate administering to help reduce ammonia levels in the blood?

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