Considering the patient's esophageal varices, which of the following nursing interventions would be appropriate in your care of the patient?

Encourage them to continue an exercise routine such as weightlifting.

Advise them to avoid straining at stools.

Provide them with hot liquids as desired.

Advise them to limit himself to one alcoholic drink per day.

Answer and Explanation

The Correct Answer is B

Choice A reason: Encouraging the patient to continue an exercise routine such as weightlifting is not appropriate for a patient with esophageal varices. Weightlifting and other strenuous activities can increase intra-abdominal pressure, which may lead to the rupture of the varices and cause severe bleeding.

Choice B reason: Advising the patient to avoid straining at stools is the correct intervention. Straining during bowel movements can increase intra-abdominal pressure and the risk of rupturing the esophageal varices. The nurse should encourage the patient to maintain soft stools through a high-fiber diet, adequate hydration, and possibly stool softeners to prevent straining.

Choice C reason: Providing hot liquids as desired is not recommended for patients with esophageal varices. Hot liquids can cause vasodilation and potentially increase the risk of bleeding from the varices. Patients should be advised to consume beverages at moderate temperatures.

Choice D reason: Advising the patient to limit themselves to one alcoholic drink per day is not appropriate. Alcohol consumption can worsen liver disease, increase portal hypertension, and exacerbate esophageal varices. Patients with esophageal varices should be advised to avoid alcohol completely to reduce the risk of complications.

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Correct Answer is ["C","D","E","F"]

Explanation

Choice A reason: Increased serum calcium is not typically associated with advanced liver disease. Hypercalcemia (increased serum calcium) may be seen in conditions like hyperparathyroidism, certain cancers, or excessive vitamin D intake, but it is not a common finding in liver disease.

Choice B reason: Decreased serum ammonia is also not associated with advanced liver disease. In fact, patients with liver disease often have increased serum ammonia levels due to the liver's inability to effectively detoxify ammonia into urea. Elevated ammonia can lead to hepatic encephalopathy, a serious complication of liver disease.

Choice C reason: Increased ALT and AST are common laboratory findings in advanced liver disease. These liver enzymes, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are released into the bloodstream when liver cells are damaged or inflamed. Elevated levels indicate liver injury or dysfunction and are often used to assess the extent of liver disease.

Choice D reason: Decreased albumin is a typical finding in advanced liver disease. Albumin is a protein produced by the liver, and its levels drop when the liver is no longer able to synthesize it effectively. Low albumin levels can lead to edema and ascites due to decreased oncotic pressure in the blood vessels.

Choice E reason: Elevated bilirubin is expected in advanced liver disease. Bilirubin is a byproduct of red blood cell breakdown that is normally processed and excreted by the liver. When liver function is impaired, bilirubin accumulates in the blood, leading to jaundice, characterized by yellowing of the skin and eyes.

Choice F reason: Elevated prothrombin time (PT) is a common finding in advanced liver disease. The liver produces clotting factors necessary for blood coagulation, and when it is damaged, these factors are not produced adequately, leading to prolonged PT. This indicates a higher risk of bleeding and impaired clotting function.

A. Instruct the client to exercise the fingers and wrist. B. Call the healthcare provider to report the loss of the radial pulse. C. Continue to assess the arm every hour for any additional changes. D. Administer morphine IV.

Correct Answer is B

Explanation

Choice A reason: Instructing the client to exercise the fingers and wrist is not the immediate priority. While maintaining mobility is important in burn care, the absence of a radial pulse indicates a potential vascular compromise that needs urgent attention.

Choice B reason: Calling the healthcare provider to report the loss of the radial pulse is the correct and immediate action. The absence of a radial pulse suggests that the edema is causing compartment syndrome, which can lead to tissue ischemia and necrosis if not promptly treated. This is a medical emergency requiring immediate intervention, possibly including a fasciotomy to relieve pressure.

Choice C reason: Continuing to assess the arm every hour for additional changes is important, but it is not the immediate priority. The absence of a radial pulse indicates a critical issue that needs immediate reporting and intervention, rather than waiting for further changes.

Choice D reason: Administering morphine IV can help manage the client's pain, which is significant at 8/10. However, it does not address the underlying issue of the absent radial pulse and potential compartment syndrome. Pain management is important but secondary to resolving the vascular compromise.

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Considering the patient's esophageal varices, which of the following nursing interventions would be appropriate in your care of the patient?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient admitted with advanced liver disease. Which laboratory result(s) would the nurse expect? Select all that apply.

Correct Answer is ["C","D","E","F"]

Explanation

A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

Correct Answer is B

Explanation

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