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?

Measurement of abdominal girth and body weight

Assessment for variceal bleeding

Assessment for signs and symptoms of jaundice

Monitoring of results of liver function testing

Answer and Explanation

The Correct Answer is B

A. Measurement of abdominal girth and body weight: Tracking abdominal girth and weight helps monitor ascites and fluid retention, which are common in cirrhosis. While important, these measurements are more useful for ongoing monitoring than as a priority in acute assessment.

B. Assessment for variceal bleeding: Variceal bleeding is a life-threatening complication of advanced cirrhosis due to portal hypertension. Esophageal or gastric varices can rupture suddenly, causing massive hemorrhage. Prompt assessment is critical to identify early signs and intervene immediately.

C. Assessment for signs and symptoms of jaundice: Jaundice reflects impaired bilirubin metabolism due to liver dysfunction. Though clinically relevant, jaundice is not immediately life-threatening compared to the risks associated with active or potential variceal bleeding.

D. Monitoring of results of liver function testing: Liver function tests are essential for understanding the extent of hepatic impairment. However, they offer delayed information and are not as urgent as clinical assessments that detect potentially fatal complications.

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Correct Answer is C

Explanation

A. Hypotension: Hypotension is a serious sign of anaphylaxis due to widespread vasodilation and capillary leakage. While it requires prompt intervention, it does not immediately compromise the airway like stridor does, making it a lower priority.

B. Urticaria: Urticaria (hives) is a common skin manifestation of allergic reactions and is generally not life-threatening. It signals histamine release but does not pose an immediate threat to airway or breathing and can be managed after stabilizing more critical symptoms.

C. Stridor: Stridor indicates upper airway obstruction and is a life-threatening manifestation of anaphylaxis. It suggests severe laryngeal edema or bronchospasm, requiring immediate intervention to secure the airway and prevent respiratory failure.

D. Vomiting: Vomiting may accompany anaphylaxis due to gastrointestinal involvement but does not present an immediate threat to airway or breathing. It is a lower priority compared to airway compromise signs such as stridor.

A. Both are inflammatory B. Both manifest fistula formation C. Both begin in the rectum D. Both require frequent surgery

Correct Answer is A

Explanation

A. Both are inflammatory: Ulcerative colitis and Crohn's disease are both types of inflammatory bowel disease (IBD). They involve chronic inflammation of the gastrointestinal tract and share symptoms such as abdominal pain, diarrhea, and weight loss.

B. Both manifest fistula formation: Fistulas are common in Crohn's disease due to transmural inflammation but are rare in ulcerative colitis, which affects only the mucosal layer of the colon. Therefore, fistula formation is not a shared feature.

C. Both begin in the rectum: Ulcerative colitis characteristically begins in the rectum and spreads proximally in a continuous pattern, while Crohn’s disease can affect any part of the GI tract from mouth to anus, often skipping areas.

D. Both require frequent surgery: While surgery can be required in both conditions for complications or treatment failure, ulcerative colitis can often be cured with total colectomy. Crohn’s disease may require multiple surgeries due to recurrence, but neither condition universally requires frequent surgery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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