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 B
Explanation
A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.
Correct Answer is A
Explanation
A) Chronic pancreatitis can lead to a decrease in enzyme production necessary for digestion, leading to malabsorption.
B) This does not typically cause malabsorption associated with chronic pancreatitis.
C) While it can occur with chronic pancreatitis, it does not directly cause malabsorption.
D) This is not related to the digestive malabsorption seen in chronic pancreatitis.
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