The nurse prepares to do a focused assessment on a client who was successfully treated for bleeding esophageal varices yesterday.
Which body system should the nurse prioritize?
Neurological.
Integumentary.
Gastrointestinal.
Renal.
The Correct Answer is C
Post-procedure assessment for esophageal varices requires prioritizing the system most likely to experience re-bleeding. Knowledge of portal hypertension and gastrointestinal assessment is necessary to monitor for therapeutic success or acute recurrence of life-threatening hemorrhage after treatment.
Choice A rationale
While neurological status is important to assess for hepatic encephalopathy in liver patients, it is not the primary system for a focused assessment immediately following a successful intervention for an active gastrointestinal bleed unless symptoms arise.
Choice B rationale
Integumentary assessment might show jaundice or bruising in liver disease, but it does not provide critical information regarding the immediate stability of the esophageal varices or the potential for a sudden recurrence of internal bleeding.
Choice C rationale
The gastrointestinal system is the priority because the client is at high risk for re-bleeding. Monitoring for hematemesis, melena, and abdominal girth helps detect early signs of failure in the variceal ligation or sclerotherapy treatment provided.
Choice D rationale
Renal function is monitored in liver failure due to the risk of hepatorenal syndrome, but it remains secondary to the gastrointestinal system during the immediate twenty-four-hour post-procedure window focused on stabilizing the variceal hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Evaluating a patient with liver failure involves understanding the biosynthetic pathways of coagulation. The liver produces vitamin K dependent clotting factors, and monitoring laboratory trends is essential to assess the severity of coagulopathy and the risk for spontaneous internal bleeding.
Choice A rationale
Urine output monitoring assesses renal perfusion and fluid balance, which is important in liver failure due to the risk of hepatorenal syndrome. However, it does not directly measure the liver ability to synthesize the essential factors needed for clotting.
Choice B rationale
Oxygen saturation measures the percentage of hemoglobin bound to oxygen in the blood. While respiratory status is important, it is not the priority assessment for a patient specifically at risk for hemorrhage due to impaired clotting factor synthesis.
Choice C rationale
Blood pressure can indicate hemodynamic stability and signs of shock if a bleed has already occurred. However, it is a late indicator of hemorrhage and does not provide information regarding the actual physiological capacity for blood coagulation.
Choice D rationale
The liver synthesizes factors I, II, VII, IX, and X. PT and INR directly measure the extrinsic pathway of coagulation. A normal PT is 11 to 13.5 seconds, and a normal INR is 0.8 to 1.1.
Correct Answer is ["A","D","E","F"]
Explanation
Diagnosing acute pancreatitis involves analyzing inflammatory markers, pancreatic enzymes, and metabolic changes. Knowledge of systemic inflammatory response syndrome and the endocrine/exocrine functions of the pancreas is necessary to identify labs indicating tissue necrosis, inflammation, and secondary metabolic disturbances.
Choice A rationale
Pancreatitis triggers a systemic inflammatory response, leading to leukocytosis. An elevated white blood cell count (normal range 5,000 to 10,000 cells/mm) is a common finding indicating active inflammation or secondary infection within the pancreatic tissue.
Choice B rationale
In acute pancreatitis, hematocrit often increases rather than decreases due to hemoconcentration. Fluid shifts from the intravascular space into the peritoneal cavity (third spacing) cause a relative rise in hematocrit, indicating significant volume depletion.
Choice C rationale
Serum amylase (normal range 30 to 110 U/L) typically increases rapidly within hours of symptom onset in pancreatitis. A decreased level is not supportive of this diagnosis; levels usually rise three times the upper limit.
Choice D rationale
Serum lipase (normal range 0 to 160 U/L) is a highly specific marker for pancreatic damage. In acute pancreatitis, lipase levels rise significantly and remain elevated longer than amylase, making it a primary diagnostic indicator.
Choice E rationale
Hypertriglyceridemia is both a cause and a result of acute pancreatitis. Serum triglycerides exceeding 1,000 mg/dL can precipitate an attack. Elevated levels support the diagnosis and help identify the potential underlying metabolic etiology.
Choice F rationale
The pancreas produces insulin via islets of Langerhans. Inflammation impairs endocrine function, leading to hyperglycemia (normal fasting glucose 70 to 99 mg/dL). Elevated glucose is a common secondary finding in acute pancreatic injury.
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