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

"I have a tight sensation in my lower leg when I forget to put my feet up."

"I can't button my pants anymore because my belly is so swollen."

"I'm very constipated and have been straining during bowel movements."

"When I sleep, I have to sit in a recliner so that I can breathe more easily."

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is ["A","B","C"]

Explanation

Tachycardia, or a rapid heartbeat, is a common response to the pain and stress associated with stomach perforation. The body’s sympathetic nervous system is activated in response to the pain and the potential shock state due to internal bleeding or infection, leading to an increased heart rate. Tachycardia is also a compensatory mechanism to maintain adequate blood flow and oxygen delivery to vital organs in the setting of decreased blood volume. A stomach perforation due to a peptic ulcer is a serious medical condition where an ulcer has led to a hole in the stomach lining. This can lead to the contents of the stomach spilling into the abdominal cavity, causing peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity).

Choice B: Rebound tenderness

Rebound tenderness is a clinical sign that indicates irritation of the peritoneum. When pressure is applied to the abdomen and then quickly released, the sudden movement of the peritoneal layers against each other produces sharp, rebound pain. This is a classic sign of peritonitis, which can occur with stomach perforation as gastric contents irritate the peritoneum. When assessing a client with a suspected stomach perforation due to a peptic ulcer, a nurse should expect to find signs of tachycardia, rebound tenderness, and a rigid abdomen. These findings are indicative of the body’s response to the acute abdominal condition and peritoneal irritation. It is crucial to recognize these signs promptly as stomach perforation is a medical emergency requiring immediate intervention.

Choice C: Rigid abdomen

A rigid abdomen is indicative of involuntary guarding, a reflex contraction of the abdominal muscles to protect inflamed organs within the abdomen. This rigidity is a sign of peritoneal irritation and is often present in cases of stomach perforation. The rigidity helps to immobilize the area, which may reduce pain but also serves as a clinical indicator of serious intra-abdominal pathology.

Choice D: Elevated blood pressure

Elevated blood pressure is not typically a direct result of stomach perforation. In fact, blood pressure may initially be normal or even low, depending on the body’s response to internal bleeding and the potential development of shock. However, pain and anxiety can cause a transient increase in blood pressure, but it is not a primary diagnostic criterion for stomach perforation.

A. "A headache is an indication of an allergy to the medication." B. "A headache is an expected adverse effect of the medication." C. "A headache is likely due to the anxiety about the chest pain." D. "A headache indicates tolerance to the medication."

Correct Answer is B

Explanation

Choice A reason:

A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions are more likely to present with symptoms such as rash, itching, or difficulty breathing.

Choice B reason:Headaches are a well-known side effect of nitroglycerin, due to its vasodilating effects, which can cause dilation of cerebral arteries.

Choice C reason:While anxiety can cause headaches, in this context, where the client has taken nitroglycerin, it is more likely that the headache is a side effect of the medication rather than anxiety.

Choice D reason:Tolerance to medication would reduce the effectiveness of the drug, not typically cause a headache. The headache is a common side effect, not an indication of tolerance.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

Correct Answer is ["A","B","C"]

Explanation

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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