A nurse is assessing a client diagnosed with cirrhosis.
Which of the following manifestations should the nurse expect?
Tarry stools.
Spider angiomas.
Moist skin.
Blood in the urine.
The Correct Answer is B
Choice A rationale
Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.
Choice B rationale
Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.
Choice C rationale
Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.
Choice D rationale
Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.
Choice B rationale
Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.
Choice C rationale
Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.
Choice D rationale
Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.
Correct Answer is C
Explanation
Choice A rationale
Administering the insulin 30 minutes after breakfast is not recommended. Regular insulin should be administered before meals.
Choice B rationale
Administering the insulin at 0700 is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.
Choice C rationale
Administering the insulin at 0730 is recommended if breakfast is at 0800. Regular insulin should be administered 30 to 45 minutes before a meal. This is the correct answer.
Choice D rationale
Administering the insulin when the breakfast tray arrives is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.
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