A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
A) Assessment of blood pressure and assessment for headaches and visual changes
B) Assessments for signs and symptoms of venous thromboembolism
C) Daily weights and abdominal girth measurement
D) Blood glucose monitoring q4h
Ans: C
Feedback:
Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
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