The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?

Frequent nosebleeds and bruising

Urinary retention

No bowel movement in three days

Increased blood glucose

Answer and Explanation

The Correct Answer is A

Choice A reason: Frequent nosebleeds and bruising are indicative of coagulopathy, a common complication in advanced cirrhosis due to the liver's impaired ability to synthesize clotting factors. This can lead to an increased tendency to bleed.

Choice B reason: Urinary retention is not typically associated with cirrhosis. Instead, cirrhosis can lead to renal dysfunction known as hepatorenal syndrome, characterized by the failure of the kidneys to filter waste from the blood².

Choice C reason: While constipation can occur in cirrhosis, no bowel movement in three days is not a direct complication of cirrhosis. However, it could be related to the overall health status of the patient or medications used.

Choice D reason: Increased blood glucose is not a direct complication of cirrhosis. Cirrhosis primarily affects the metabolism of proteins and fats and does not directly cause hyperglycemia unless there is concurrent diabetes or metabolic syndrome.

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Correct Answer is ["167"]

Explanation

- Step 1: Identify the client's weight in pounds. The client weighs 245 lbs.

- Step 2: Convert the client's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 245 lbs = 245 ÷ 2.2 kg. Calculating the division gives us approximately 111.36 kg.

- Step 3: Identify the prescribed dose in mg/kg. The client is scheduled to receive 1.5 mg/kg of enoxaparin.

- Step 4: Calculate the total dose in mg. We can do this by multiplying the client's weight in kg by the prescribed dose in mg/kg:

- Total dose = 1.5 mg/kg × 111.36 kg.

- Calculating the multiplication gives us approximately 167.04 mg.

- Step 5: Round the total dose to the nearest whole number. Rounding 167.04 gives us 167.

administer 167 mg of enoxaparin per dose.

A. Administer antiemetics as needed. B. Administer analgesics as needed. C. NPO (nothing by mouth) until pain-free. D. Monitor blood glucose and provide insulin as needed. E. Side-lying or fetal position. F. Monitor hydration status.

Correct Answer is ["A","B","C","D","F"]

Explanation

Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.

Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.

Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.

Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.

Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.

Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.

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The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["167"]

Explanation

A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).

Correct Answer is ["A","B","C","D","F"]

Explanation

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