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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Obtain the client's vital signs:
Vital signs are essential for assessing the client's overall condition and can provide crucial information about the client's stability. However, in this scenario, there's a higher priority nursing action that needs immediate attention.

B. Weigh the client:
Daily weight measurement is important, especially in postoperative patients, to monitor for fluid retention or loss. However, this is not the most urgent action in this situation.

C. Change the client's dressing:
Changing the dressing involves maintaining the surgical site's cleanliness and preventing infections. While this is important, it's not the highest priority in this situation.

D. Administer pain medication:
Correct Choice. Addressing the client's pain is a priority to ensure their comfort and well-being, especially postoperatively. Managing pain effectively is crucial for the client's recovery and can facilitate other necessary activities, such as changing the dressing or weighing the client.

A. Keep the head of the bed elevated at 15 degrees. B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding C. Flush the tube with 30 ml of water every 4 hr. D. Change the feeding bag and tubing every 72 hr.

Correct Answer is C

Explanation

A. Keep the head of the bed elevated at 15 degrees.

This is not sufficient for preventing aspiration and ensuring proper digestion. The head of the bed should be elevated at least 30 degrees to reduce the risk of aspiration and promote better digestion of enteral feedings.

B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding: It is recommended to change the feeding formula and bag every 24 hours. Placing formula for an extended period can increase the risk of bacterial growth.

C. Flush the tube with 30 ml of water every 4 hr: Regular flushing of the tube helps maintain patency, prevents clogging, and ensures proper hydration. Flushing every 4 hours is a standard practice for continuous feeding.

D. Change the feeding bag and tubing every 72 hr: Feeding bags and tubing should be changed more frequently, typically every 24 hours, to reduce the risk of infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

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?

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