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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) While important, it is not directly related to the coagulopathy indicated by the prolonged PT.
B) Important for overall fluid management but not directly related to the risk of bleeding.
C) With a significantly prolonged PT, assessing for signs of gastrointestinal bleeding is a priority.

D) Important for safety, but the immediate risk of bleeding due to coagulopathy takes precedence.

A. Review diet history B. Obtain a dietary consult C. Administer IV fluids D. Send stool for fecal fat

Correct Answer is D

Explanation

A) While reviewing the diet history is important to understand nutritional intake and habits, it is not the priority action in this case.
B) Consulting a dietitian is important but should follow an assessment that identifies the specific issue causing the symptoms.
C) This action may be necessary if the patient is dehydrated but doesn’t address the primary concern of foul-smelling stools and weight loss.
D) This test is crucial as it helps confirm the diagnosis of malabsorption, which is likely given the patient’s history of chronic pancreatitis and symptoms described. This would be the priority to confirm the cause of the symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes these laboratory results for a client with cirrhosis: PT 20 seconds (11-12.5 sec) and serum ammonia 35 mcg/dL (15-45 mcg/dL). What action by the nurse would be a priority?

Correct Answer is C

Explanation

A client with a history of chronic pancreatitis reports weight loss of 10 pounds over the last month and foul smelling stools. What would be a priority action for the nurse to take?

Correct Answer is D

Explanation

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