A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?
Risk for bleeding
Risk for activity intolerance
Risk for impaired nutrition: less than body requirements
Risk for impaired skin integrity
The Correct Answer is A
A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.
B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) These are dilated veins in the esophagus that can rupture and lead to life- threatening bleeding.
B) While concerning and indicative of hepatic encephalopathy, it is not immediately life-threatening like a variceal bleed.
C) Indicates poor nutritional status and liver function but is not as acutely dangerous as bleeding varices.
D) This is a concern but does not represent an immediate life-threatening condition like esophageal varices.
Correct Answer is B
Explanation
A) Bradycardia is not typically associated with hepatic encephalopathy.
B) Asterixis is a characteristic finding in hepatic encephalopathy, known as "flapping tremor," indicating neuromuscular irritability due to elevated blood ammonia levels.
C) Fever is not a common direct symptom of hepatic encephalopathy.
D) Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.
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