A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?
Hematemesis
Ascites
Splenomegaly
Varices
The Correct Answer is D
A) Hematemesis refers to vomiting of blood and is a symptom that can occur as a result of bleeding from esophageal varices or other gastrointestinal sources.
B) Ascites is the accumulation of fluid in the abdominal cavity, leading to abdominal distension. It is not related to the presence of visible distended veins on the abdomen and chest.
C) Splenomegaly is the enlargement of the spleen and is not related to the finding of visible distended veins.
D) Varices are dilated and tortuous veins that can develop in various locations, including the esophagus (esophageal varices) and the abdomen and chest wall (caput medusae). In liver cirrhosis, portal hypertension causes increased pressure in the portal vein, leading to the development of these enlarged veins. Esophageal varices can be life-threatening if they rupture and cause severe bleeding.
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Related Questions
Correct Answer is C
Explanation
A) While adequate protein intake is important for overall health, encouraging the client to increase protein intake is not a priority in managing ascites. The priority is to address fluid retention through diuretic therapy.
B) While ambulation can be beneficial for clients with liver cirrhosis, it is not the priority for managing ascites. Diuretic therapy is more directly targeted at reducing fluid accumulation.
C) The priority nursing intervention for managing ascites in a client with liver cirrhosis is administering diuretics as prescribed by the healthcare provider. Diuretics help reduce fluid retention and alleviate the pressure caused by the accumulation of fluid in the abdomen. This intervention aims to improve the client's comfort and prevent the development of further complications associated with ascites.
D) Deep breathing exercises can be helpful for clients with liver cirrhosis, but they are not the priority for managing ascites. The focus should be on diuretic therapy and addressing the fluid retention in the abdomen.
Correct Answer is D
Explanation
A) Lactulose is used to treat hepatic encephalopathy and is not prescribed to reduce the risk of bleeding from esophageal varices.
B) Omeprazole is a proton pump inhibitor used to reduce stomach acid production and treat conditions such as peptic ulcers and gastroesophageal reflux disease (GERD). While it may be prescribed to manage gastritis or peptic ulcers, it is not primarily used to reduce the risk of bleeding from esophageal varices.
C) Furosemide is a diuretic used to manage fluid retention and ascites in clients with liver cirrhosis. It is not prescribed to reduce the risk of bleeding from esophageal varices.
D) Propranolol is a beta-blocker commonly used to reduce the risk of bleeding from esophageal varices in clients with liver cirrhosis. Propranolol helps decrease portal hypertension by reducing the pressure in the portal vein, thereby reducing the likelihood of variceal rupture and bleeding.
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