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: Rapid pulse. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause rapid pulse due to increased sympathetic nervous system activity and decreased cardiac output.

Choice B: Clammy skin. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia. Hypoglycemia can cause clammy skin due to increased sweating and vasoconstriction.

Choice C: Choice C: Confusion is commonly found in HHS rather than DKA.

Choice D: Polydipsia. This is a finding that indicates that the client is experiencing DKA due to the high level of glucose in the blood. Hyperglycemia in DKA can cause polydipsia, which is excessive thirst, due to osmotic diuresis and dehydration.

A. Faty stools B. Ecchymosis of the extremities C. Straw-colored urine D. Tenderness in the left upper abdomen

Correct Answer is A

Explanation

Choice A: Faty stools. This is a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis, which is the presence of gallstones in the gallbladder or bile ducts. The common bile duct carries bile from the liver and gallbladder to the duodenum, where it helps digest fats. If the common bile duct is obstructed by a gallstone, bile cannot reach the duodenum and fats cannot be properly absorbed. This results in fatty stools, which are also known as steatorrhea. Fatty stools are pale, bulky, greasy, and foul-smelling.

Choice B: Ecchymosis of the extremities. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Ecchymosis of the extremities is a sign of bleeding under the skin, which can be caused by trauma, coagulation disorders, or medications. It is not related to bile duct obstruction or gallstones.

Choice C: Straw-colored urine. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Straw-coloured urine is a normal colour of urine, which indicates adequate hydration and kidney function. It is not aﬀected by bile duct obstruction or gallstones.

Choice D: Tenderness in the left upper abdomen. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Tenderness in the left upper abdomen is a sign of splenomegaly, which is an enlargement of the spleen due to infection, inﬂammation, or cancer. It is not related to bile duct obstruction or gallstones.

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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

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