Identify two causes of ascites related to liver cirrhosis:
Poor nutrition related to alcoholism results in abdominal obesity.
Portal hypertension pushes proteins from the blood vessels, causing leakage into the peritoneal cavity.
Osmoreceptors in the hypothalamus stimulate thirst, which causes the patient to take in excessive fluids orally.
There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin.
Correct Answer : B,D
Choice A reason: Poor nutrition related to alcoholism can lead to abdominal obesity, but it is not a direct cause of ascites in liver cirrhosis. Ascites is primarily due to factors like portal hypertension and decreased colloid oncotic pressure.
Choice B reason: Portal hypertension is a significant cause of ascites in liver cirrhosis. The increased pressure in the portal vein causes proteins to leak from the blood vessels into the peritoneal cavity, leading to fluid accumulation.
Choice C reason: Osmoreceptors in the hypothalamus stimulating thirst can lead to excessive fluid intake, but this is not a direct cause of ascites related to liver cirrhosis. Ascites is more directly linked to portal hypertension and decreased colloid oncotic pressure.
Choice D reason: Decreased colloid oncotic pressure due to the liver's inability to synthesize albumin is a key factor in the development of ascites. Albumin helps maintain fluid balance in the blood vessels, and its deficiency leads to fluid leakage into the peritoneal cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypoglycemia typically presents with symptoms such as sweating, trembling, hunger, confusion, and in severe cases, loss of consciousness. The patient's symptoms of sudden right-sided weakness and difficulty speaking are more consistent with a neurological event rather than low blood sugar levels.
Choice B reason: Hemorrhagic stroke involves bleeding within the brain. Although it can present with similar symptoms to ischemic stroke, the diagnostic tests indicate no evidence of hemorrhage. This makes a hemorrhagic stroke less likely.
Choice C reason: Ischemic stroke occurs when a blood clot blocks a blood vessel in the brain, leading to reduced blood flow and oxygen to a part of the brain. The patient's symptoms of sudden right-sided weakness and expressive aphasia are classic signs of an ischemic stroke, and the absence of hemorrhage on the head CT scan supports this diagnosis.
Choice D reason: Multiple sclerosis (MS) is a chronic, progressive disease that affects the central nervous system. It usually presents with episodic neurological symptoms rather than the sudden onset seen in this patient. MS symptoms develop over time and can vary widely, whereas the patient's acute presentation is more indicative of a stroke.
Correct Answer is B
Explanation
Choice A reason: Asking the patient about loose stools is important as it can help identify possible causes of fluid and electrolyte imbalances. However, this question alone would not be the immediate or primary action to take in response to generalized weakness.
Choice B reason: Suggesting that the healthcare provider order a basic metabolic panel is the most appropriate action. Potassium-wasting diuretics can lead to hypokalemia, which can cause symptoms like generalized weakness. A basic metabolic panel will provide information on the patient's electrolyte levels, including potassium, and help determine if the weakness is due to an electrolyte imbalance. This allows for appropriate intervention to correct the imbalance and prevent further complications.
Choice C reason: Assessing for facial muscle spasms is relevant because hypokalemia can cause muscle cramps and spasms. However, it does not address the root cause of the weakness and does not lead to immediate intervention.
Choice D reason: Calling for a rapid response team is generally reserved for situations where the patient is experiencing acute, life-threatening symptoms requiring immediate intervention. Generalized weakness in the context of a patient on a potassium-wasting diuretic does not usually necessitate such an urgent response unless it progresses to more severe symptoms.
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