The nurse is assessing a client with esophageal varices. Which of these findings would be early indicators of bleeding?
Epigastric fullness and increasing combativeness
Yellow sclera, hypertension, and hypoalbuminemia
Bradycardia, lethargy, and hypotension
Tachycardia, restlessness, and pallor
The Correct Answer is D
Choice A reason: Epigastric fullness may suggest variceal pressure, but combativeness isn’t typical early bleeding; it’s more neurological, not a direct blood loss sign.
Choice B reason: Yellow sclera and hypoalbuminemia reflect liver dysfunction, not acute bleeding; hypertension contradicts blood loss, which lowers pressure initially.
Choice C reason: Bradycardia and lethargy occur late in severe hypovolemia, not early; hypotension fits bleeding but isn’t paired with early compensatory signs here.
Choice D reason: Tachycardia compensates for early blood loss in varices, restlessness reflects hypoxia, and pallor shows reduced perfusion, all classic initial bleeding indicators.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Captopril, an ACE inhibitor, lowers blood pressure, risking orthostatic hypotension; teaching posture changes (slow standing) prevents falls, a key safety instruction.
Choice B reason: Captopril is taken on an empty stomach for optimal absorption, as food reduces bioavailability, so this statement contradicts proper administration guidelines.
Choice C reason: Cough, an ACE inhibitor side effect, doesn’t warrant suppressants; it may require switching drugs, not masking, making this instruction inappropriate.
Choice D reason: Captopril can raise potassium by reducing aldosterone; high-potassium foods risk hyperkalemia, so this advice is unsafe without monitoring levels.
Correct Answer is D
Explanation
Choice A reason: Steak, a solid, requires chewing and swallowing coordination, risking aspiration in dysphagia post-CVA due to impaired pharyngeal muscle control.
Choice B reason: Iced tea, a thin liquid, flows quickly, increasing aspiration risk in CVA patients with weakened swallow reflexes, unable to manage thin consistencies safely.
Choice C reason: Grapes, small and round, pose choking and aspiration hazards in dysphagia, as they require intact bolus control, often compromised post-stroke.
Choice D reason: Mashed potatoes, soft and thick, are easier to swallow, reducing aspiration risk in dysphagia post-CVA, aligning with thickened consistency recommendations.
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