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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) While an elevated WBC count may indicate infection, it is not unexpected in acute pancreatitis.
B) Serum potassium within normal range does not require immediate intervention.
C) Serum albumin within normal range does not require immediate intervention.
D) Lipase levels significantly elevated above the normal range indicate ongoing pancreatic inflammation and may require intervention or adjustment of treatment.
Correct Answer is A
Explanation
A) Chronic damage to the pancreas can lead to diabetes mellitus due to the destruction of insulin-producing cells.
B) Jaundice is typically associated with liver disease, not directly linked with chronic pancreatitis.
C) Ascites is a complication of liver disease, not typically a direct result of chronic pancreatitis.
D) While steatorrhea is a symptom of chronic pancreatitis due to malabsorption of fats, it is not a complication but rather a direct effect of the enzyme insufficiency.
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