A patient is admitted with esophageal varices and portal hypertension. Which underlying cause of these conditions would the nurse suspect?
Liver cirrhosis
Throat lacerations
Kyphosis
Squamous cell cancer
The Correct Answer is A
Choice A rationale
Liver cirrhosis is the most common cause of esophageal varices and portal hypertension. Cirrhosis leads to scarring of the liver, which impedes blood flow through the portal vein, causing increased pressure (portal hypertension) and the development of collateral blood vessels (varices) as the body attempts to bypass the blockage.
Choice B rationale
Throat lacerations are not related to the development of esophageal varices or portal hypertension. They are typically acute injuries and do not cause the chronic changes seen in the vasculature associated with these conditions.
Choice C rationale
Kyphosis, a curvature of the spine, does not cause esophageal varices or portal hypertension. It is a structural skeletal condition and does not affect the vasculature of the esophagus or the portal venous system.
Choice D rationale
While squamous cell cancer can occur in the esophagus, it is not a typical cause of portal hypertension or esophageal varices. These varices are usually a result of increased pressure in the portal vein, not directly from a malignancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale
Chocolate is known to have moderate levels of potassium and should be limited in a diet for chronic kidney disease to prevent hyperkalemia¹.
Choice B rationale
Green beans are considered a lower potassium vegetable and can be included in a kidney-friendly diet in appropriate portions².
Choice C rationale
Tomatoes are high in potassium and should be avoided by individuals with chronic kidney disease to maintain safe potassium levels¹.
Choice D rationale
Bananas are very high in potassium and are one of the most well-known foods that individuals with chronic kidney disease are advised to avoid¹.
Choice E rationale
Asparagus is lower in potassium compared to other vegetables and can be consumed in moderation by people with chronic kidney disease².
Choice F rationale
Salt substitutes often contain potassium chloride and should be avoided as they can significantly increase potassium intake, which is harmful for those with chronic kidney disease¹.
Correct Answer is A
Explanation
Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.
Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.
Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.
Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.
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