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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.
Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.
Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.
Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.
Correct Answer is A
Explanation
Choice A reason: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure. This is because the full bladder sends signals to the spinal cord, which then attempts to send signals to the brain. However, due to the injury, these signals cannot pass through, resulting in a reflex that increases blood pressure.
Choice B reason: While a severe headache is a symptom of autonomic dysreflexia, it is not a cause. The headache results from the body's response to a triggering stimulus, such as a distended bladder, which leads to the high blood pressure characteristic of autonomic dysreflexia.
Choice C reason: Nasal congestion is not typically a cause of autonomic dysreflexia. The condition is usually triggered by a noxious stimulus below the level of the spinal cord injury, such as a full bladder or bowel, skin irritation, or other types of physical discomfort.
Choice D reason: Elevated blood pressure is a symptom, not a cause, of autonomic dysreflexia. The condition itself causes a sudden spike in blood pressure due to an uncontrolled reflex sympathetic discharge in response to a triggering stimulus below the level of the injury.
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