The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?

"I have a tight sensation in my lower leg when I forget to put my feet up."

"I can't button my pants anymore because my belly is so swollen."

"I'm very constipated and have been straining during bowel movements."

"When I sleep, I have to sit in a recliner so that I can breathe more easily."

Answer and Explanation

The Correct Answer is B

Choice A: “I have a tight sensation in my lower leg when I forget to put my feet up.” This statement may indicate the presence of edema, which is common in cirrhosis due to hypoalbuminemia and sodium retention. However, it is not as immediately concerning as other symptoms because it can often be managed with diuretics and compression. It is important to monitor for worsening edema, as it can lead to increased discomfort and risk of skin breakdown.

Choice B: “I can’t button my pants anymore because my belly is so swollen.” This statement is concerning because it suggests the development of ascites, which is the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Ascites can lead to abdominal discomfort, difficulty breathing, and is a sign of advanced liver disease with significant portal hypertension. It requires medical evaluation and management, which may include paracentesis (removal of fluid), diuretics, and sodium restriction. Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver.

Choice C: “I’m very constipated and have been straining during bowel movements.” While constipation is uncomfortable and can indicate dietary issues or side effects from medication, it is not typically a direct complication of cirrhosis or portal hypertension. However, straining during bowel movements can increase the risk of bleeding from esophageal varices if they are present, so it is important to manage constipation to prevent potential complications.

Choice D: “When I sleep, I have to sit in a recliner so that I can breathe more easily.” This statement indicates orthopnea, which can be associated with ascites or pleural effusions (fluid in the lungs), both of which can occur in the setting of cirrhosis and portal hypertension. While this symptom is concerning and affects the client’s quality of life, it is generally less concerning than the development of ascites, as it can be managed with adjustments in sleeping position and medical management of the underlying fluid accumulation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Title: Choice A reason: Beta-blocking agent Beta-blocking agents are often used in the management of cirrhosis of the liver. They are particularly useful in managing portal hypertension, a common complication of cirrhosis. Beta-blockers lower elevated portal pressure and protect against variceal hemorrhage, a serious complication of portal hypertension. Therefore, a beta-blocking agent may be ordered for a client with cirrhosis of the liver.

Title: Choice B reason: Diuretic Diuretics are commonly used in the management of fluid retention, a frequent complication in patients with cirrhosis. Fluid retention can lead to conditions such as ascites (abdominal fluid accumulation) and edema (swelling in the legs, feet, or ankles)2. Diuretics help to remove excess fluid from the body, thereby managing these symptoms. Therefore, a diuretic may be ordered for a client with cirrhosis of the liver.

Title: Choice C reason: Opioid analgesic While opioid analgesics are powerful pain relievers, they should be used with caution in patients with cirrhosis of the liver. Opioids can precipitate hepatic encephalopathy, a condition characterized by altered mental status and neuromuscular dysfunction, which is a serious complication of cirrhosis. Therefore, an opioid analgesic may not be the best choice for a client with cirrhosis of the liver.

Title: Choice D reason: Lactulose Lactulose is a non-absorbable sugar that is widely used in the treatment of hepatic encephalopathy, a common complication in patients with cirrhosis. It works by reducing the absorption of ammonia in the gut, thereby lowering blood ammonia levels and improving symptoms of hepatic encephalopathy. Therefore, lactulose may be ordered for a client with cirrhosis of the liver.

Title: Choice E reason: Sedative Sedatives should be used with caution in patients with cirrhosis of the liver. Like opioids, they can precipitate hepatic encephalopathy. Therefore, a sedative may not be the best choice for a client with cirrhosis of the liver.

A. Severe fluid and electrolyte imbalance B. Upper abdominal distention C. Metabolic acidosis D. Projectile vomiting with a fecal odor E. Diarrhea or ribbon-like stools

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

No explanation

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)

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

Explanation

The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).

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

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?

A nurse is teaching an ACLS class and is discussing heart rhythms and treatment. Which of the following rhythms would indicate the need for defibrillation?

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?

A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).

A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings indicate an increased risk of acute kidney injury (AKI)?