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 A

Explanation

Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.

Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.

Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.

Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.

A. Obtain the client’s vital signs. B. Weigh the client. C. Administer pain medication. D. Change the client’s dressing.

Correct Answer is C

Explanation

Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, ﬂuid imbalance, or shock, but these are not as urgent as relieving the client’s pain.

Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their ﬂuid status and nutritional needs, but this can be done after addressing the client’s pain.

Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and aﬀect their quality of life.

Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.

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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?

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Explanation

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Explanation

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