the nurse is caring for a client with cirrhosis which manifestations indicate deficient vitamin k absorption caused by this liver disease

ATI RN

ATI Gastrointestinal System

1. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

A. Dyspnea and fatigue
B. Ascites and orthopnea
C. Purpura and petechiae
D. Gynecomastia and testicular atrophy

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

2. The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:

A. Upper quadrant and radiates to the left scapula and shoulder
B. Upper quadrant and radiates to the right scapula and shoulder
C. Lower quadrant and radiates to the umbilicus
D. Lower quadrant and radiates to the back

Correct answer: B

Rationale: Pain from cholecystitis is typically located in the right upper quadrant and may radiate to the right scapula and shoulder.

3. Which of the following symptoms best describes Murphy’s sign?

A. Periumbilical ecchymosis exists
B. On deep palpation and release, pain is elicited
C. On deep inspiration, pain is elicited and breathing stops
D. Abdominal muscles are tightened in anticipation of palpation

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

4. Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?

A. Profuse vomiting.
B. Cramping abdominal pain.
C. Abdominal distention.
D. High-pitched bowel sounds above the obstruction.

Correct answer: A

Rationale: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. Abdominal discomfort and distention are present in both small and large bowel obstructions, but distention is more common in large bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

5. Which of the following conditions can cause a hiatal hernia?

A. Increased intrathoracic pressure
B. Weakness of the esophageal muscle
C. Increased esophageal muscle pressure
D. Weakness of the diaphragmic muscle

Correct answer: D

Rationale: Weakness of the diaphragmic muscle can lead to a hiatal hernia as it allows part of the stomach to push through the diaphragm into the chest cavity.