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:Increased serum amylase is a common finding in acute pancreatitis as it is released from the inflamed pancreas[^10^].
Choice B reason:A decreased WBC count is not typically associated with acute pancreatitis; an increased count may indicate infection or inflammation.
Choice C reason:Serum calcium is often decreased in acute pancreatitis due to fat saponification and hypoalbuminemia.
Choice D reason:Decreased serum lipase would not be expected; increased levels are indicative of acute pancreatitis, similar to amylase[^10^].
Correct Answer is B
Explanation
Choice A: Instruct the client to lean forward This action is not related to the assessment of asterixis. Leaning forward can be part of the physical examination for other conditions, such as assessing for spinal issues or abdominal pain, but it does not provoke the characteristic flapping motion of the hands seen in asterixis.
Choice B: Ask the client to extend the arms This is the correct method to assess for asterixis. The patient is asked to extend their arms and dorsiflex their wrists. The nurse then observes for any involuntary flapping movements of the hands, which would indicate the presence of asterixis. This sign is indicative of a disturbance in the central nervous system’s regulation of muscle tone, often due to metabolic liver dysfunction. To assess for asterixis, the nurse should ask the client to extend their arms, which is the standard method for eliciting this sign. The presence of asterixis can help in the diagnosis of hepatic encephalopathy and other metabolic conditions affecting the brain’s control of muscle tone.
Choice C: Dorsiflex the client’s foot Dorsiflexion of the foot is not a method used to assess for asterixis. While changes in muscle tone can be assessed in the lower limbs, asterixis is specifically a hand tremor and is best observed in the upper extremities.
Choice D: Measure the abdominal girth Measuring abdominal girth is relevant in the assessment of ascites, which can occur in cirrhosis, but it is not a method for assessing asterixis. Ascites refers to the accumulation of fluid in the peritoneal cavity, leading to increased abdominal size, which is a common complication of cirrhosis.
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