A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?

Weak pulse

Dark colored stools

Spider angioma

Increased body hair

Answer and Explanation

The Correct Answer is C

Choice A: Weak pulse. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. A weak pulse may indicate hypovolemia, shock, or cardiac dysfunction, but it is not directly related to liver disease.

Choice B: Dark colored stools. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Dark colored stools may indicate bleeding in the upper gastrointestinal tract, such as from esophageal varices or peptic ulcers, but they are not specific to liver disease.

Choice C: Spider angioma. This is a manifestation that the nurse should expect to find in a client who has advanced cirrhosis, which is a chronic liver disease that causes scarring and impaired liver function. Spider angioma is a type of vascular lesion that appears as a red spot with radiating branches on the skin, usually on the face, neck, chest, or upper arms. It is caused by increased estrogen levels due to reduced liver metabolism of hormones.

Choice D: Increased body hair. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Increased body hair may indicate hypertrichosis, which is excessive hair growth due to genetic, hormonal, or metabolic factors, but it is not related to liver disease.

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Correct Answer is D

Explanation

Choice A: Implement neutropenia isolation. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Neutropenia isolation is a type of protective isolation that is used for

clients who have low white blood cell counts and are at risk of infection from others. It is not indicated for clients who have Clostridium difficile infection, which is not transmited through the air.

Choice B: Use alcohol hand sanitizer following client care. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Alcohol hand sanitizer is ineﬀective against Clostridium difficile spores and can increase the risk of transmission. The nurse should wash their hands with soap and water, which can remove the spores from the skin.

Choice C: Monitor the client for manifestations of ﬂuid overload. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Fluid overload is a condition that occurs when the body retains excess ﬂuid and causes symptoms such as edema, dyspnea, and hypertension. It is not related to Clostridium difficile infection, which can cause ﬂuid loss due to diarrhea and dehydration. The nurse should monitor the client for manifestations of ﬂuid deficit, such as dry mucous membranes, tachycardia, and hypotension.

Choice D: Disinfect equipment with bleach solution. This is an action that the nurse should take for a client who has developed a Clostridium difficile infection, which is a bacterial infection that causes severe diarrhea and inﬂammation of the colon. Clostridium difficile spores are resistant to most disinfectants and can survive on surfaces for a long time. The nurse should disinfect equipment with bleach solution, which can kill the spores and prevent transmission.

A. Check for bleeding on the dressing at the back of the client’s neck. B. Ensure that acetylcysteine IV is readily available. C. Place the client in a side-lying position. D. Check the client for asterixis.

Correct Answer is A

Explanation

Choice A: Check for bleeding on the dressing at the back of the client’s neck. This is an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy, which is a surgical removal of part of the thyroid gland. The nurse should check for bleeding on the dressing at the back of the client’s neck because this is where blood can pool and go unnoticed. Bleeding can cause hematoma, compression of the airway, and respiratory distress.

Choice B: Ensure that acetylcysteine IV is readily available. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Acetylcysteine IV is an antidote for acetaminophen overdose, which can cause liver damage, but it is not related to thyroid surgery.

Choice C: Place the client in a side-lying position. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. The nurse should place the client in a semi-Fowler’s position, which is a position with the head of the bed elevated to 30 to 45 degrees. This position can facilitate breathing, reduce edema, and prevent aspiration.

Choice D: Check the client for asterixis. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Asterixis is a sign of hepatic encephalopathy, which is a condition caused by liver failure, but it is not related to thyroid surgery.

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A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

Correct Answer is A

Explanation

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