The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
Decreased renin-angiotensin response related to an increase in renal blood flow.
Decreased portacaval pressure with greater collateral circulation.
Hypoalbuminemia that results in a decreased colloidal oncotic pressure
The Correct Answer is D
A. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
Hyperaldosteronism is characterized by an excess of aldosterone, a hormone that regulates sodium and water balance. In cirrhosis, however, sodium retention is often related to other mechanisms such as portal hypertension and hypoalbuminemia, rather than hyperaldosteronism.
B. Decreased renin-angiotensin response related to an increase in renal blood flow.
Cirrhosis is more commonly associated with an activated renin-angiotensin-aldosterone system, leading to increased sodium and water retention. The increased renin-angiotensin response is a compensatory mechanism to maintain perfusion in the setting of cirrhosis and does not contribute to decreased renal blood flow.
C. Decreased portacaval pressure with greater collateral circulation.
This statement is not accurate. In cirrhosis, there is typically increased portacaval pressure due to portal hypertension, which can lead to the development of collateral circulation. However, this does not explain the edema and ascites seen in cirrhosis.
D. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
This is the correct choice. In cirrhosis, liver damage leads to decreased synthesis of albumin. Albumin plays a crucial role in maintaining colloidal oncotic pressure, and when it is decreased (hypoalbuminemia), fluid is more likely to leak out of blood vessels, resulting in edema. The same mechanism contributes to the development of ascites in the abdominal cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Discuss approaches to chronic pain control with the client:
This is the correct answer. Heberden's nodes are bony enlargements that can occur in osteoarthritis, particularly in the joints of the fingers. These nodes can be associated with pain. Discussing approaches to chronic pain control with the client is an appropriate nursing intervention to address the client's pain and improve quality of life.
B. Review the client's dietary intake of high-protein foods:
Dietary intake of high-protein foods is not directly related to the management of Heberden's nodes in degenerative joint disease. Pain control and joint protection measures are more relevant.
C. Notify the healthcare provider of the finding immediately:
While it's important to communicate significant findings to the healthcare provider, the presence of Heberden's nodes in degenerative joint disease may not require immediate notification unless there are other concerning symptoms or complications.
D. Assess the client's radial pulses and capillary refill time:
Assessing radial pulses and capillary refill time is not directly related to managing Heberden's nodes in degenerative joint disease. These nodes are primarily a result of joint changes in osteoarthritis.
Correct Answer is B
Explanation
A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.
B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.
C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.
D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.
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