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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Pain medication is not appropriate for managing altered mental status and confusion. The priority is to identify and address the underlying cause of the client's symptoms.
B) While documentation and ongoing monitoring are important, the priority is to take immediate action when the client is exhibiting signs of altered mental status. The nurse should promptly notify the healthcare provider for further evaluation and intervention.
C) A liver biopsy is a diagnostic procedure that provides information about the degree of liver damage and fibrosis. However, it is not the first action to take when the client is experiencing altered mental status and confusion. Immediate notification of the healthcare provider is the priority in this situation.
D) Altered mental status and confusion in a client with liver cirrhosis can indicate hepatic encephalopathy, a serious complication of advanced liver disease. Hepatic encephalopathy results from the accumulation of toxic substances in the blood due to impaired liver function. The nurse should prioritize notifying the healthcare provider immediately to initiate appropriate interventions and prevent further deterioration of the client's condition.
Correct Answer is C
Explanation
A) This statement is incorrect. Even moderate alcohol intake can be harmful to a client with liver cirrhosis. Alcohol should be completely avoided to prevent exacerbation of liver damage.
B) This statement is incorrect. The client should not resume their previous alcohol consumption habits. Continued alcohol consumption can lead to further liver damage and complications.
C) For a client with liver cirrhosis, alcohol consumption should be completely avoided. Alcohol is a significant contributor to liver damage and can worsen the condition, leading to further complications. Abstinence from alcohol is crucial to prevent further liver injury and improve the client's overall prognosis.
D) This statement is incorrect. The client should not consume any type of alcoholic beverage. All forms of alcohol can be harmful to the liver, and complete abstinence is necessary for individuals with liver cirrhosis.
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