Gastrointestinal Question #7

Question

A client with advanced cirrhosis is admitted to the intensive care unit. Which assessment will the nurse prioritize when developing the plan of care?

Answers

  1. Monitoring liver function tests daily.
    • Rationale:
  2. Assessing for jaundice.
    • Rationale:
  3. Assessing for variceal bleeding.
    • Rationale:
  4. Measuring weight and abdominal girth.
    • Rationale:

Overview

Explanation

Esophageal varices occur in 30% of clients with compensated cirrhosis and 60% with decompensated cirrhosis. They are the main source of bleeding and will increase mortality rates with the first bleeding episode. Mortality increases for acute bleeding and recurrence of bleeding. This makes the monitoring for bleeding a priority with cirrhosis. The other options (A, B, D) are important interventions but assessing for bleeding is most important.

Learning Outcomes

Test Taking Tip

Video Rationale