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 C

Explanation

Choice A: Topical ointment Topical ointment forms of nitroglycerin are used for their long-acting effects. The medication is absorbed slowly through the skin, providing a steady level of drug in the bloodstream. This form is not designed for rapid relief of acute angina attacks but rather for prevention.

Choice B: Sustained-release Sustained-release forms of nitroglycerin are designed to release the medication slowly over an extended period. This route is also not suitable for treating acute symptoms because it does not provide immediate relief but is used for long-term management of angina pectoris. Nitroglycerin is a medication used primarily to treat angina pectoris (chest pain) and heart failure. It works by relaxing the smooth muscles and dilating the blood vessels, which increases blood flow to the heart and decreases its workload. The route of administration can significantly affect the onset and duration of the medication’s action.

Choice C: Sublingual The sublingual route, where the medication is placed under the tongue, allows for rapid absorption into the bloodstream through the rich supply of blood vessels found in the area. This form of nitroglycerin acts quickly, usually within 1 to 3 minutes, and is the preferred choice for immediate relief of angina pain. When rapid onset is required for relief from acute angina symptoms, the sublingual route is the most appropriate choice for administering nitroglycerin. It provides quick absorption and fast action, making it an essential treatment option for patients experiencing chest pain due to angina.

Choice D: Transdermal patch Transdermal patches release nitroglycerin slowly through the skin and into the bloodstream. Like topical ointments and sustained-release forms, they are used for long-term prophylaxis of angina and not for rapid relief.

A. Troponin B. Aspartate aminotransferase (AST) C. Serum amylase D. Unconjugated bilirubin

Correct Answer is A

Explanation

Choice A: Troponin Troponin levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. Troponin is a protein found in cardiac muscle fibers that regulates muscular contraction. When heart muscle is damaged, as in the case of an MI, troponin is released into the bloodstream. The elevation of troponin levels is a key indicator of myocardial infarction and can be used to diagnose and assess the extent of heart muscle damage. Troponin is the most reliable laboratory value that is expected to be elevated following a myocardial infarction, making it the correct choice in this scenario.

Choice B: Aspartate aminotransferase (AST) AST is an enzyme found in high concentrations in the liver, heart, muscles, kidneys, and brain. It is released into the bloodstream when any of these tissues are damaged. While AST can be elevated in cases of MI, it is not as specific as troponin because it is present in many other tissues besides the heart.

Choice C: Serum amylase Serum amylase is an enzyme that helps digest carbohydrates and is primarily associated with the pancreas and salivary glands. Its elevation is not specifically related to myocardial infarction but can be seen in other conditions such as pancreatitis.

Choice D: Unconjugated bilirubin Unconjugated bilirubin is a breakdown product of hemoglobin from red blood cells. Elevated levels of unconjugated bilirubin are typically associated with conditions affecting the liver or the breakdown of red blood cells, not myocardial infarction.

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 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?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hours ago. The nurse should expect which of the following laboratory values to be elevated?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory test results from a client who has acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?

A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?

The nurse is monitoring a client who just finished a meal for vasomotor manifestations of dumping syndrome. Which of the following findings indicate this occurrence?

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

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?