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 A
Explanation
Choice A reason: Dizziness and pallor are common vasomotor symptoms of early dumping syndrome. They result from the rapid shift of fluid into the intestine, leading to a decrease in blood volume and a temporary decrease in blood pressure.
Choice B reason: Abdominal cramping and pain are gastrointestinal symptoms of dumping syndrome but are not specifically vasomotor manifestations. They occur due to the rapid entry of hyperosmolar contents into the small intestine.
Choice C reason: Bradycardia is not typically a symptom of dumping syndrome. Instead, tachycardia is more commonly observed due to the body's response to the rapid changes in the gastrointestinal tract and blood volume.
Choice D reason: Double vision and chest pain are not typical symptoms of dumping syndrome. These symptoms may indicate other medical conditions and should be evaluated separately.
Correct Answer is A
Explanation
Choice A reason:Lactulose is used in hepatic encephalopathy primarily to lower blood ammonia levels. It works by converting ammonia in the intestines into ammonium, which is then excreted³. Therefore, a decrease in ammonia levels would indicate the effectiveness of the medication.
Choice B reason:While lactulose can relieve constipation due to its laxative effect, relief of constipation is not the primary indicator of its effectiveness in treating hepatic encephalopathy³.
Choice C reason:Decreased liver enzymes are not a direct measure of lactulose's effectiveness in hepatic encephalopathy. Liver enzymes are indicators of liver function, not ammonia levels³.
Choice D reason:Relief of abdominal pain is not a specific indicator of lactulose's effectiveness in hepatic encephalopathy. The medication's primary role is to reduce ammonia levels, not to alleviate pain³.
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