The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?

Frequent nosebleeds and bruising

Urinary retention

No bowel movement in three days

Increased blood glucose

Answer and Explanation

The Correct Answer is A

Choice A reason: Frequent nosebleeds and bruising are indicative of coagulopathy, a common complication in advanced cirrhosis due to the liver's impaired ability to synthesize clotting factors. This can lead to an increased tendency to bleed.

Choice B reason: Urinary retention is not typically associated with cirrhosis. Instead, cirrhosis can lead to renal dysfunction known as hepatorenal syndrome, characterized by the failure of the kidneys to filter waste from the blood².

Choice C reason: While constipation can occur in cirrhosis, no bowel movement in three days is not a direct complication of cirrhosis. However, it could be related to the overall health status of the patient or medications used.

Choice D reason: Increased blood glucose is not a direct complication of cirrhosis. Cirrhosis primarily affects the metabolism of proteins and fats and does not directly cause hyperglycemia unless there is concurrent diabetes or metabolic syndrome.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A: “I have a tight sensation in my lower leg when I forget to put my feet up.” This statement may indicate the presence of edema, which is common in cirrhosis due to hypoalbuminemia and sodium retention. However, it is not as immediately concerning as other symptoms because it can often be managed with diuretics and compression. It is important to monitor for worsening edema, as it can lead to increased discomfort and risk of skin breakdown.

Choice B: “I can’t button my pants anymore because my belly is so swollen.” This statement is concerning because it suggests the development of ascites, which is the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Ascites can lead to abdominal discomfort, difficulty breathing, and is a sign of advanced liver disease with significant portal hypertension. It requires medical evaluation and management, which may include paracentesis (removal of fluid), diuretics, and sodium restriction. Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver.

Choice C: “I’m very constipated and have been straining during bowel movements.” While constipation is uncomfortable and can indicate dietary issues or side effects from medication, it is not typically a direct complication of cirrhosis or portal hypertension. However, straining during bowel movements can increase the risk of bleeding from esophageal varices if they are present, so it is important to manage constipation to prevent potential complications.

Choice D: “When I sleep, I have to sit in a recliner so that I can breathe more easily.” This statement indicates orthopnea, which can be associated with ascites or pleural effusions (fluid in the lungs), both of which can occur in the setting of cirrhosis and portal hypertension. While this symptom is concerning and affects the client’s quality of life, it is generally less concerning than the development of ascites, as it can be managed with adjustments in sleeping position and medical management of the underlying fluid accumulation.

A. Lower extremity edema B. Crackles in lung bases C. Jugular vein distention D. Ascites

Correct Answer is B

Explanation

Choice A reason:Lower extremity edema is more commonly associated with right-sided heart failure, as it indicates systemic fluid congestion.

Choice B reason:Crackles in lung bases are expected in left-sided heart failure due to pulmonary congestion from fluid backing up into the lungs².

Choice C reason:Jugular vein distention is typically a sign of right-sided heart failure, reflecting increased central venous pressure.

Choice D reason:Ascites, the accumulation of fluid in the peritoneal cavity, is generally associated with right-sided heart failure or liver disease, not specifically left-sided heart failure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?

Correct Answer is B

Explanation

A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?

A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?

A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

A nurse is reviewing the laboratory test results from a client who has acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

The healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?