a client is experiencing esophageal varices secondary to liver cirrhosis what is the primary goal of care for this client
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Nursing Elites

ATI LPN

ATI Learning System PN Medical Surgical Final Quizlet

1. What is the primary goal of care for a client experiencing esophageal varices secondary to liver cirrhosis?

Correct answer: B

Rationale: The primary goal of care for a client with esophageal varices secondary to liver cirrhosis is to control bleeding. Esophageal varices are fragile, enlarged veins in the esophagus that can rupture and lead to life-threatening bleeding. Controlling bleeding is crucial to prevent severe complications and ensure the client's safety and well-being. Preventing infection (Choice A) is important but not the primary goal in this case. Reducing portal hypertension (Choice C) is a long-term goal that may help prevent variceal bleeding but is not the immediate priority. Maintaining nutritional status (Choice D) is essential for overall health but is secondary to controlling bleeding in this critical situation.

2. The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?

Correct answer: D

Rationale: The correct answer is D because losing weight in an infant, especially when combined with spitting up milk, requires immediate intervention to address potential health concerns. Choice A deals with a cultural practice that may not necessarily pose an immediate health risk. Choice B, while important, does not present an immediate health threat. Choice C relates to cultural differences in communication and does not necessarily indicate a need for immediate intervention in terms of health.

3. When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?

Correct answer: D

Rationale: In therapeutic communication, silence can offer the client an opportunity to process their emotions and thoughts. By remaining silent, the nurse provides a space for the client to reflect on their own words, facilitating deeper exploration and understanding of their feelings.

4. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

5. The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

Correct answer: B

Rationale: Prothrombin time (PT) is monitored to ensure therapeutic levels of warfarin and prevent bleeding complications.

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