A client with portal hypertension has bluish veins just under the skin of the abdomen that radiate out across the umbilicus. Which pathophysiological factors does the nurse recognize causes this condition? Select all that apply.
A) Elevated bilirubin levels
B) Impaired clearance of ammonia
C) Increased fluid in the abdomen
D) Impaired metabolism of estrogens
E) Increased abdominal pressure
C) Increased fluid in the abdomen
E) Increased abdominal pressure
Explanation: A) Elevated bilirubin, impaired clearance of ammonia, and impaired metabolism of estrogens may occur with liver impairment; however, these are not pathophysiological factors caused by portal hypertension.
B) Elevated bilirubin, impaired clearance of ammonia, and impaired metabolism of estrogens may occur with liver impairment; however, these are not pathophysiological factors caused by portal hypertension.
C) Caput medusa is an abnormal assessment finding in the client with portal hypertension. The abdomen has bluish veins just under the skin that radiate out across the umbilicus as a result of ascites and increased abdominal pressure.
D) Elevated bilirubin, impaired clearance of ammonia, and impaired metabolism of estrogens may occur with liver impairment; however, these are not pathophysiological factors caused by portal hypertension.
E) Caput medusa is an abnormal assessment finding in the client with portal hypertension. The abdomen has bluish veins just under the skin that radiate out across the umbilicus as a result of ascites and increased abdominal pressure.
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