A nurse is caring for a client with liver cirrhosis and notices that the client's platelet count is significantly decreased. Which complication of liver cirrhosis is the likely cause of this finding?
Portal hypertension
Ascites
Hepatocellular carcinoma
Splenomegaly
The Correct Answer is A
A) In liver cirrhosis, portal hypertension occurs due to increased pressure in the portal vein, which carries blood from the intestines to the liver. The increased pressure leads to the development of portosystemic collaterals (collateral circulation) to divert blood flow. This can cause hypersplenism, a condition where the spleen becomes enlarged and traps platelets, leading to a decreased platelet count (thrombocytopenia).
B) Ascites is the accumulation of fluid in the abdominal cavity and is not directly related to a decreased platelet count.
C) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not the likely cause of the client's decreased platelet count.
D) Splenomegaly (enlargement of the spleen) can occur in liver cirrhosis due to portal hypertension. However, splenomegaly itself is not the cause of the decreased platelet count; it is the hypersplenism resulting from the splenomegaly that causes thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A) Iron supplements are not a priority intervention for a client with hepatic encephalopathy. In fact, administering iron supplements without proper indication can be harmful, as excessive iron can worsen liver damage in cirrhosis.
B) While monitoring fluid intake and output is important in managing various aspects of liver cirrhosis, it is not the essential intervention for hepatic encephalopathy. The priority in hepatic encephalopathy is to ensure seizure precautions and address the client's altered mental status.
C) Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis that can lead to altered mental status, confusion, and potential seizures. Implementing seizure precautions is essential in the care of this client to ensure their safety and prevent injury during any potential seizure activity. Seizure precautions may include padding the side rails of the bed, ensuring a clear and clutter-free environment, and providing close supervision to the client. In severe cases, the healthcare provider may prescribe antiepileptic medications to manage and prevent seizures.
D) Encouraging a high-protein diet is not appropriate for a client with hepatic encephalopathy. High-protein diets can exacerbate hepatic encephalopathy by increasing ammonia production in the intestines. Instead, the client should be prescribed a controlled-protein diet and, in some cases, given lactulose to help reduce ammonia levels.
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