the nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension which initial sign if not the nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension which initial sign if not
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?

Correct answer: D

Rationale: Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.

2. A nurse is caring for a client who has osteoarthritis. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: In osteoarthritis, joint pain that improves with rest is a common characteristic due to the relief obtained by reducing weight-bearing on the affected joint. Joint stiffness that improves with movement is more indicative of rheumatoid arthritis, not osteoarthritis. Red, warm joints are typically seen in inflammatory arthritis conditions like rheumatoid arthritis, while systemic inflammation is not a primary feature of osteoarthritis.

3. Before the nurse researcher starts her study, she analyzes how much time, money, materials and people she will need to complete the research project. This analysis prior to beginning the study is called:

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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

Correct answer: B

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

5. For administering a cleansing enema, what is the common position typically used?

Correct answer: A

Rationale: The correct position for administering a cleansing enema is the Sims left lateral position. This position is preferred as it helps to facilitate the procedure by allowing gravity to assist in the flow of the enema solution. The individual lies on their left side with the right knee flexed towards the chest, which helps to promote retention of the enema solution and its distribution throughout the colon. Choices B, C, and D are incorrect. The dorsal recumbent position (Choice B) is commonly used for physical examinations of the abdomen and genitalia. The supine position (Choice C) involves lying flat on the back and is not ideal for administering enemas. The prone position (Choice D) is lying flat on the stomach and is not suitable for administering enemas.

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