A nurse is caring for a client with liver cirrhosis and notices that the client's platelet count is significantly decreased. Which complication of liver cirrhosis is the likely cause of this finding?
Portal hypertension
Ascites
Hepatocellular carcinoma
Splenomegaly
The Correct Answer is A
A) In liver cirrhosis, portal hypertension occurs due to increased pressure in the portal vein, which carries blood from the intestines to the liver. The increased pressure leads to the development of portosystemic collaterals (collateral circulation) to divert blood flow. This can cause hypersplenism, a condition where the spleen becomes enlarged and traps platelets, leading to a decreased platelet count (thrombocytopenia).
B) Ascites is the accumulation of fluid in the abdominal cavity and is not directly related to a decreased platelet count.
C) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not the likely cause of the client's decreased platelet count.
D) Splenomegaly (enlargement of the spleen) can occur in liver cirrhosis due to portal hypertension. However, splenomegaly itself is not the cause of the decreased platelet count; it is the hypersplenism resulting from the splenomegaly that causes thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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 B
Explanation
A) While lactulose can be taken with meals to minimize gastrointestinal discomfort, its effectiveness is not necessarily enhanced by taking it with meals. The timing and dosage of lactulose should be based on the healthcare provider's instructions.
B) Lactulose is a medication commonly used to manage hepatic encephalopathy in clients with liver cirrhosis. It works by reducing ammonia levels in the blood by promoting the excretion of ammonia through the stool. The nurse should instruct the client to expect one to two soft bowel movements per day while on lactulose, as this indicates the medication's effectiveness in removing ammonia from the body.
C) Lactulose is not associated with fluid overload, and there is no need to limit fluid intake while taking the medication. In fact, adequate hydration is important in clients with liver cirrhosis.
D) Lactulose is not known to significantly affect blood glucose levels, and there is no specific need for the client to monitor blood glucose levels while taking this medication.
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