When planning care for a patient with esophageal varices, which action would be a priority for the nurse?
A) Discussing the importance of Alcoholics Anonymous meetings
B) Assessing for signs and symptoms of hemorrhage
C) Teaching the patient signs of bleeding to report
D) Encouraging rest periods to reduce fatigue
B) Assessing for signs and symptoms of hemorrhage
Explanation: A) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue.
B) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue.
C) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue.
D) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue.
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