A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?
Hematemesis
Brown, foarmy urine.
Clay-colored stool.
Anorexia.
The Correct Answer is A
A Hematemesis refers to vomiting blood, which can occur when esophageal varices rupture and bleed into the gastrointestinal tract. It is a hallmark sign of upper gastrointestinal bleeding and requires immediate medical attention. Monitoring for hematemesis allows for early detection of variceal bleeding and prompt intervention to prevent further complications.
B Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders.
C Clay-colored stool may indicate a lack of bile in the stool, which can occur in conditions affecting the liver or bile ducts, such as obstructive jaundice.
D Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. However, while anorexia may impact nutritional status and overall health, it is not directly related to the complications of esophageal varices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A hydrocolloidal gel dressing can be beneficial as it maintains moisture and supports autolytic debridement. This type of dressing also helps in protecting the wound from external contaminants and can be left in place for several days, depending on the level of exudate.
B. Replacing the gauze with a transparent dressing, which is typically used for minimal to moderate exudating wounds, could dry out the wound or those that are not designed for significant granulation tissue
C. Leaving the dressing off is not advisable as it exposes the wound to potential infection and delays healing.
D. Increasing the frequency of dressing changes is not specified as a standard treatment and could potentially disrupt the healing process.
Correct Answer is A
Explanation
A Preventing esophageal reflux is essential in managing symptoms associated with a direct hiatal hernia. Nursing interventions may include promoting proper positioning (elevating the head of the bed), encouraging smaller, more frequent meals, avoiding trigger foods, and administering medications as prescribed to reduce acid reflux.
B Promoting intestinal peristalsis may be beneficial in certain gastrointestinal conditions, such as constipation but it is not directly related to the management of a direct hiatal hernia.
C Promoting effective swallowing is important for overall swallowing function and preventing aspiration in some cases, it may not directly address the symptoms or complications associated with a direct hiatal hernia.
D Maintaining intact oral mucosa is important for oral health and preventing complications such as oral mucositis, but it is not directly related to the management of a direct hiatal hernia.
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