A nurse is assessing a client with chronic liver failure who tells the nurse he is experiencing spontaneous episodes of bleeding and has noted increased areas of bruising on his arms. The nurse suspects the client has a deficiency in which of the following vitamins?
Thiamine
Vitamin C
Vitamin K
Folic acid
The Correct Answer is C
A. Thiamine deficiency is often associated with neurological symptoms, such as Wernicke-Korsakoff syndrome, rather than spontaneous bleeding or bruising. Thiamine does not directly impact the coagulation process.
B. Vitamin C deficiency can lead to scurvy, which includes symptoms such as bleeding gums and poor wound healing. However, it is not typically associated with the spontaneous bleeding and bruising seen in chronic liver failure.
C. Vitamin K is essential for the synthesis of clotting factors produced by the liver. In chronic liver failure, the liver's ability to produce these factors is impaired, leading to an increased risk of bleeding and bruising due to vitamin K deficiency.
D. Folic acid deficiency is more commonly linked to anemia and certain neurological issues, but it does not cause spontaneous bleeding or bruising. It does not directly affect coagulation factors as vitamin K does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
B. While pain is a significant concern and should be managed, it is not as immediately life-threatening as potential airway obstruction.
C. A respiratory rate of 24 breaths per minute is elevated but within the range of mild tachypnea, which could be due to pain or anxiety, and is not the most urgent finding.
D. Urinary output of 25 mL/hr is below normal and indicates possible hypovolemia or kidney injury, but airway concerns take precedence in this scenario.
Correct Answer is A
Explanation
A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is crucial for managing SLE and preventing flare-ups. This demonstrates the client's understanding of the importance of medication adherence.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is known to exacerbate SLE. This statement reflects an understanding of the need to reduce stress to manage the disease effectively.
D. Wearing protective clothing when going outside is essential to prevent sun exposure, which can trigger SLE flare-ups. This indicates that the client understands the need for sun protection.
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