A nurse caring for a client with hepatitis is providing education to the client about portal hypertension. Which of the following will the nurse include in the teaching?
"Increased pressure from portal hypertension contributes to the abdominal swelling."
"Portal hypertension is caused by the heart overworking."
"Portal hypertension develops when the cirrhosis begins to resolve."
"Eating high sodium foods and a stressful lifestyle contribute to portal hypertension."
The Correct Answer is A
Choice A reason: This is the correct answer because portal hypertension means that there is high blood pressure in the portal vein, which carries blood from the digestive organs to the liver. When the liver is damaged by hepatitis, it becomes scarred and obstructs the blood flow, causing increased pressure in the portal vein. This leads to fluid accumulation in the abdomen, called ascites, which causes abdominal swelling.
Choice B reason: This is incorrect because portal hypertension is not caused by the heart overworking but by liver damage. The heart does not pump blood into the portal vein, but into the hepatic artery, which supplies oxygenated blood to the liver.
Choice C reason: This is incorrect because portal hypertension does not develop when cirrhosis begins to resolve, but when it progresses. Cirrhosis is a chronic condition that causes irreversible scarring of the liver tissue, which worsens over time and increases portal hypertension.
Choice D reason: This is incorrect because eating high-sodium foods and a stressful lifestyle do not cause portal hypertension, but they can aggravate it. High-sodium foods can increase fluid retention and worsen ascites, while stress can increase blood pressure and worsen bleeding complications. The nurse should advise the client to limit sodium intake and manage stress levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is correct because first degree burns are superficial burns that affect only the outer layer of the skin, called the epidermis. First degree burns cause redness, pain, and mild swelling, but no blisters or scarring. They usually heal within a week.
Choice B Reason: This is incorrect because second degree burns are partial thickness burns that affect both the epidermis and the underlying layer of the skin, called the dermis. Second degree burns cause blisters, severe pain, and possible infection. They may take several weeks to heal and may leave scars.
Choice C Reason: This is incorrect because third degree burns are full thickness burns that destroy all layers of the skin and may damage the underlying tissues, such as muscles, nerves, or bones. Third degree burns cause charred or white skin, numbness, and shock. They require skin grafting and may cause permanent disability or death.
Choice D Reason: This is incorrect because this burn can be classified according to the depth and extent of the skin damage. The classification of burns helps to determine the appropriate treatment and prognosis for the client.
Correct Answer is C
Explanation
Choice A Reason: Educating the client about the therapy is an important action by the nurse, but not the priority one. The nurse should explain the purpose, procedure, benefits, and risks of hydrotherapy to the client before starting it, but only after ensuring their comfort and pain relief.
Choice B Reason: Providing analgesics after therapy ends is not enough, as the nurse should provide them before and during therapy as well. Hydrotherapy involves cleansing and debriding of burn wounds with water jets or whirlpools, which can be very painful and stressful for the client.
Choice C Reason: This is the correct choice. Providing analgesics before therapy begins is the priority action by the nurse, as it reduces pain and anxiety for the client and facilitates wound healing. The nurse should assess the client's pain level and administer appropriate analgesics at least 30 minutes before hydrotherapy.
Choice D Reason: Ensuring there are clean supplies is an essential action by the nurse, but not the priority one. The nurse should use sterile or clean equipment and solutions for hydrotherapy to prevent infection and contamination of burn wounds, but only after ensuring their comfort and pain relief.
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