A nurse in a clinic is caring for a client who has alcohol use disorder. The client reports frequent bruising and nosebleeds. Which of the following conditions should the nurse suspect?
Diabetes mellitus
Hepatitis A
Cirrhosis
Cholecystitis
The Correct Answer is C
A. Diabetes mellitus
Diabetes mellitus can cause easy bruising and slow wound healing, but it is not typically associated with frequent nosebleeds.
B. Hepatitis A
Hepatitis A primarily affects the liver and does not cause frequent bruising and nosebleeds.
C. Cirrhosis
Cirrhosis, which is scarring of the liver tissue due to long-term liver damage, can lead to impaired liver function. One consequence of cirrhosis is decreased production of clotting factors, which can result in easy bruising. Additionally, the enlarged spleen in cirrhosis can lead to thrombocytopenia (low platelet count), contributing to bleeding tendencies, including nosebleeds. Cirrhosis is the most likely condition given the symptoms described.
D. Cholecystitis
Cholecystitis is inflammation of the gallbladder and is not directly associated with frequent bruising and nosebleeds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prior to percussing the abdomen:Auscultation should be performed before percussing or palpating the abdomen. Percussion and palpation can alter bowel activity, potentially leading to inaccurate assessment of bowel sounds.
B. Prior to inspecting the abdomen:Inspection should always be performed before auscultation when assessing the abdomen. This allows the nurse to observe any visible abnormalities, such as distention or skin changes, without altering bowel activity. Auscultation should follow inspection.
C. After checking for kidney tenderness:Checking for kidney tenderness (e.g., costovertebral angle tenderness) involves percussing the back and is not part of the sequence of a standard abdominal exam. It does not precede auscultation.
D. After palpating the abdomen:
Palpation can stimulate or alter bowel sounds, potentially leading to an inaccurate assessment. Therefore, auscultation should always occur before palpation.
Correct Answer is D
Explanation
A. Place the client in a supine position.
Placing the client in a high Fowler's position (sitting upright) is the appropriate position for inserting a nasogastric tube. This position helps facilitate the passage of the tube through the nasopharynx and into the esophagus and stomach.
B. Withdraw the tube if the client gags during insertion.
Gagging during insertion is a normal response. Advancing the tube slowly and having the client swallow can help pass the tube through the nasopharynx.
C. Measure the tube for insertion from the tip of the nose to the umbilicus.
The correct measurement for insertion is from the tip of the nose to the earlobe and then down to the xiphoid process (not the umbilicus).
D. Instruct the client to place his chin to his chest and swallow.
This instruction is appropriate. Asking the client to flex their head slightly forward and swallow helps guide the tube into the esophagus.
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