A patient with cirrhosis has black, tarry stools but no vomiting. Which assessment should the nurse perform first?
Correct answer: A. Assess blood pressure, pulse and mental status
- A. Assess blood pressure, pulse and mental status
- B. Offer a high-fibre meal to prevent constipation
- C. Administer an oral iron tablet with juice
- D. Encourage walking to stimulate bowel activity
Explanation
Black tarry stool may indicate upper gastrointestinal bleeding, so circulation and neurological status must be assessed first. Food, iron and ambulation do not address possible blood loss and could delay recognition of deterioration.
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About Gastrointestinal and Liver Nursing
Covers nursing care for peptic ulcer disease, gastroenteritis, inflammatory bowel disease, intestinal obstruction, hepatitis, cirrhosis and portal hypertension. It includes nutrition, fluid and electrolyte management, abdominal assessment, gastrointestinal bleeding, ascites and hepatic encephalopathy, which must be distinguished from other causes of altered consciousness.
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