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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["24"]
Explanation
- Step 1: Identify the prescribed dose in units per hour. The client is scheduled to receive 1,200 units/hr of heparin.
- Step 2: Identify the concentration of the available solution. The available solution contains 25,000 units of heparin in 500 mL D5W.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 25,000 units is to 500 mL as 1,200 units is to X mL.
- In other words, 25,000 units : 500 mL = 1,200 units : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 25,000 units × X mL = 1,200 units × 500 mL.
- Simplifying this gives us: 25,000X = 600,000.
- Dividing both sides by 25,000 gives us: X = 600,000 ÷ 25,000.
- Calculating the division gives us: X = 24.
Set the IV pump to deliver 24 mL/hr to administer the required dose of 1,200 units/hr.
Correct Answer is D
Explanation
Choice A reason: Anorexia, or loss of appetite, is not typically a direct manifestation of left-sided heart failure. While it can be associated with many medical conditions and may occur in the context of heart failure due to overall decreased well-being, it is not a specific indicator of left-sided heart failure.
Choice B reason: Weight gain can be associated with heart failure, but it is more commonly a sign of right-sided heart failure, where fluid accumulates in the body tissues, causing swelling and weight increase. In left-sided heart failure, weight gain is not as prominent because the primary issue is the backup of blood into the lungs, not fluid retention in the tissues.
Choice C reason: A distended abdomen can occur in heart failure due to fluid accumulation; however, it is more characteristic of right-sided heart failure, where the failure of the right ventricle leads to systemic congestion, including the abdominal area. In left-sided heart failure, the primary effect is on the lungs, not the abdomen.
Choice D reason: Dyspnea, or difficulty breathing, is a hallmark symptom of left-sided heart failure. It occurs due to the backup of blood in the pulmonary circulation, which leads to pulmonary congestion and reduced oxygen exchange. Patients may experience shortness of breath, especially during exertion or when lying flat (orthopnea), and may wake up at night with shortness of breath (paroxysmal nocturnal dyspnea).
Left-sided heart failure, often caused by conditions like valvular heart disease, leads to a decrease in the heart’s ability to pump blood effectively. This results in a buildup of pressure in the lungs, manifesting as dyspnea, which is an important symptom for nurses and other healthcare providers to recognize and manage promptly.
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