. A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?
Monitoring of results of liver function testing
Assessment for signs and symptoms of jaundice
Measurement of abdominal girth and body weight
Assessment for variceal bleeding
The Correct Answer is C
A. Monitoring of results of liver function testing: While important, monitoring liver function tests is a routine assessment rather than a prioritized one compared to assessing for complications like ascites.
B. Assessment for signs and symptoms of jaundice: Jaundice is a common finding in cirrhosis but does not necessarily indicate an acute complication.
C. Measurement of abdominal girth and body weight: In advanced cirrhosis, monitoring for ascites and fluid retention is critical as these indicate worsening disease and potential complications.
D. Assessment for variceal bleeding: Incorrect. While important, the priority in routine assessment is monitoring for ascites and fluid overload, which can be managed more readily.
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Related Questions
Correct Answer is B
Explanation
A. Inability of the liver to manufacture bile: This does not directly cause esophageal varices or bleeding.
B. A scarred liver results in Portal Hypertension: Cirrhosis leads to scarring of the liver, which increases resistance to blood flow and causes portal hypertension. This elevated pressure in the portal venous system leads to the development of esophageal varices, which can rupture and bleed.
C. An elevated level of copper: Elevated copper levels are associated with Wilson's disease, not the cause of esophageal variceal bleeding in cirrhosis.
D. Inability of the liver to convert NH3 to urea: This causes hepatic encephalopathy but is not related to variceal bleeding.
Correct Answer is D
Explanation
A. Grey-Turner Sign: Grey-Turner Sign refers to bruising along the flanks, often associated with retroperitoneal hemorrhage or acute pancreatitis.
B. Steatorrhea: Steatorrhea refers to fatty stools that are pale, bulky, and foul-smelling, indicating malabsorption, not a physical exam finding on the skin.
C. Asterixis: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, seen in hepatic encephalopathy, not a skin finding.
D. Cullen's Sign: Cullen's Sign is bruising around the umbilicus, indicating intra-abdominal bleeding, often seen in conditions such as acute pancreatitis or ruptured ectopic pregnancy.
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