A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?

Hematemesis

Ascites

Splenomegaly

Varices

Answer and Explanation

The Correct Answer is D

A) Hematemesis refers to vomiting of blood and is a symptom that can occur as a result of bleeding from esophageal varices or other gastrointestinal sources.

B) Ascites is the accumulation of fluid in the abdominal cavity, leading to abdominal distension. It is not related to the presence of visible distended veins on the abdomen and chest.

C) Splenomegaly is the enlargement of the spleen and is not related to the finding of visible distended veins.

D) Varices are dilated and tortuous veins that can develop in various locations, including the esophagus (esophageal varices) and the abdomen and chest wall (caput medusae). In liver cirrhosis, portal hypertension causes increased pressure in the portal vein, leading to the development of these enlarged veins. Esophageal varices can be life-threatening if they rupture and cause severe bleeding.

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Correct Answer is A

Explanation

B) Furosemide is a diuretic used to treat fluid retention in clients with cirrhosis but is not effective in reducing ammonia levels or managing hepatic encephalopathy.

C) Propranolol is a beta-blocker often prescribed to reduce portal hypertension and prevent variceal bleeding in clients with liver cirrhosis. It is not used to treat hepatic encephalopathy.

D) Spironolactone is a diuretic used to manage fluid retention and ascites in clients with liver cirrhosis. Like furosemide, it is not effective in reducing ammonia levels or treating hepatic encephalopathy.

A. Serum potassium levels B. Blood glucose levels C. White blood cell count D. Serum calcium levels

Correct Answer is A

Explanation

A) Spironolactone is a potassium-sparing diuretic commonly used to manage fluid retention in liver cirrhosis. The nurse should monitor the client's serum potassium levels regularly as this medication can cause hyperkalemia (elevated potassium levels). It is important to assess potassium levels to avoid complications associated with imbalances in potassium levels.

B) Monitoring blood glucose levels is not specifically related to the use of spironolactone in liver cirrhosis. Spironolactone does not have a significant effect on blood glucose levels.

C) Monitoring the white blood cell count is not directly related to the use of spironolactone. White blood cell count is typically monitored to assess for signs of infection or immune system response.

D) Monitoring serum calcium levels is not directly related to the use of spironolactone in liver cirrhosis. Spironolactone does not significantly impact calcium levels in the blood.

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A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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