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?

Anorexia

Brown, foamy urine.

Clay-colored stool

Hematemesis

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Anorexia is a common symptom of cirrhosis, but it is not the most immediate concern in a client with esophageal varices.
Anorexia can result from various factors, including impaired liver function, hormonal imbalances, early satiety due to ascites,
and nausea.
While it's important to address anorexia to maintain nutritional status, it doesn't directly indicate a life-threatening
complication like bleeding varices.
Choice B rationale:
Brown, foamy urine is a characteristic of kidney problems, specifically proteinuria.
It's not directly associated with esophageal varices or their complications.
While cirrhosis can affect kidney function due to fluid imbalances and impaired filtering, brown, foamy urine wouldn't be the
primary indicator of bleeding varices.
Choice C rationale:
Clay-colored stool is a sign of biliary obstruction, which can occur in cirrhosis due to impaired bile flow.
However, it's not a direct indicator of bleeding varices.
Clay-colored stool results from a lack of bile pigments in the stool, which give it its typical brown color.
Choice D rationale:
Hematemesis, or vomiting of blood, is the most critical symptom to monitor in a client with esophageal varices.
Here's why:
Esophageal varices are enlarged, swollen veins in the esophagus that develop due to increased pressure in the portal venous
system, a common consequence of cirrhosis.
These varices are fragile and prone to rupture, which can lead to massive, life-threatening bleeding.
Hematemesis is a clear sign that variceal bleeding has occurred and requires immediate intervention.

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Correct Answer is D

Explanation

Rationale for Choice A: Dysrhythmia

There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia.

Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications.

While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias.

Rationale for Choice B: Toxicity

There is no information in the question stem to suggest that the patient is experiencing toxicity.

Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins.

While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity.

Rationale for Choice C: Anemia

There is no information in the question stem to suggest that the patient is anemic.

Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood.

While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia.

Rationale for Choice D: Pneumonia

The patient is a 51-year-old male with a diagnosis of pneumonia.

Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi.

The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia.

Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia.

Therefore, pneumonia is the most likely condition that the patient has based on the information provided.

A. Draw air in through the nose and exhale slowly through pursed lips. B. Lay down on each side with knees bent and breathe from the abdomen. C. Increase breathing rate for a full 30 seconds. D. Raise hands above the head to expand the diaphragm.

Correct Answer is A

Explanation

Rationale for Choice A:

Pursed-lip breathing:

Creates back pressure in the airways, which helps to keep them open longer during exhalation.

Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.

Promotes relaxation and reduces anxiety, which can also help to improve breathing.

Rationale for Choice B:

Side-lying position with knees bent:

May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.

May not be comfortable for all clients.

Rationale for Choice C:

Increasing breathing rate:

Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.

Rationale for Choice D:

Raising hands above the head:

Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is A

Explanation

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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?