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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Raising the voice volume to a shout can be startling for the client and may come across as aggressive or disrespectful.
B. Exaggerating nonverbal expressions might not effectively address the client's difficulty in hearing. While nonverbal communication is essential, especially for older adults with hearing impairments, exaggerating gestures may not necessarily improve communication clarity.
C. Speaking more slowly can help the client better understand what is being said without the nurse needing to shout, which might cause discomfort or further confusion.
D.Over-enunciating or exaggerating expressions can appear patronizing, and shouting can be distressing.

A. Explain that the need to restrict fluids is the primary limitation. B. Instruct the client to avoid foods with gluten, such as wheat bread. C. Describe the use of an elimination diet to find trigger foods. D. Advise the client to limit foods that are high in calcium and Iron.

Correct Answer is C

Explanation

C. Describing the use of an elimination diet to find trigger foods is a helpful approach. Crohn's disease can have trigger foods that worsen symptoms like abdominal pain, diarrhea, and bloating. By eliminating potential trigger foods one at a time and observing symptom changes, the client can identify which foods exacerbate their condition.

A. Explaining that the need to restrict fluids is the primary limitation is incorrect. Crohn's disease doesn't typically require fluid restriction unless complications like severe diarrhea or dehydration occur.

B. Instructing the client to avoid foods with gluten, such as wheat bread, is also not accurate unless the client has been diagnosed with celiac disease or has a gluten sensitivity.

D. Advising the client to limit foods that are high in calcium and iron is not generally recommended unless there are specific issues like intestinal strictures or obstructions that limit absorption.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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