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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) While adequate protein intake is important for overall health, encouraging the client to increase protein intake is not a priority in managing ascites. The priority is to address fluid retention through diuretic therapy.
B) While ambulation can be beneficial for clients with liver cirrhosis, it is not the priority for managing ascites. Diuretic therapy is more directly targeted at reducing fluid accumulation.
C) The priority nursing intervention for managing ascites in a client with liver cirrhosis is administering diuretics as prescribed by the healthcare provider. Diuretics help reduce fluid retention and alleviate the pressure caused by the accumulation of fluid in the abdomen. This intervention aims to improve the client's comfort and prevent the development of further complications associated with ascites.
D) Deep breathing exercises can be helpful for clients with liver cirrhosis, but they are not the priority for managing ascites. The focus should be on diuretic therapy and addressing the fluid retention in the abdomen.
Correct Answer is D
Explanation
A) Serum albumin is a protein synthesized by the liver, and its levels are often decreased in advanced liver cirrhosis due to impaired liver function. However, the question asks for an elevated finding, not a decreased one.
B) Prothrombin time (PT) measures the time it takes for blood to clot. In liver cirrhosis, PT is often prolonged due to impaired liver function and reduced production of clotting factors. However, the question asks for an elevated finding, not a prolonged one.
C) Aspartate aminotransferase (AST) is an enzyme found in the liver and other organs. While AST levels may be elevated in liver cirrhosis, it is not a specific marker for liver cirrhosis, and its elevation can occur in various liver diseases and conditions.
D) In liver cirrhosis, impaired liver function leads to reduced clearance of bilirubin, resulting in elevated total bilirubin levels in the blood. Elevated bilirubin is a common finding in liver cirrhosis and can contribute to jaundice.
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