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 B
Explanation
B. Aspiration can lead to serious respiratory complications such as pneumonia. Since the client reports difficulty swallowing (dysphagia) and has a high pain level, addressing the risk for aspiration is crucial to prevent further complications.
A. While nutrition is essential for overall health, it may not be the priority in this case given the severity of other symptoms such as pain, dysphagia, and anxiety.
C. Esophageal cancer can cause significant pain due to tissue destruction by the tumor, which can affect the client's quality of life and ability to function. This however, should be addressed after immediate concerns in the ABCs.
D. While addressing the client's emotional needs is important for holistic care, it may not be the immediate priority compared to managing symptoms such as pain and dysphagia,
Correct Answer is C
Explanation
C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.
A. The client's primary issue appears to be respiratory distress rather than fever.
B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.
D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.
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