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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Dysphagia. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Dysphagia is difficulty swallowing, which can be caused by disorders of the esophagus, throat, or nervous system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Choice B: Pathologic fractures. This is a complication that the nurse should monitor the client for who has hyperparathyroidism, which is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH). PTH regulates calcium and phosphorus levels in the blood and bones. Hyperparathyroidism can cause hypercalcemia, which is a high level of calcium in the blood, and hypophosphatemia, which is a low level of phosphorus in the blood. These imbalances can lead to bone resorption, which is the breakdown of bone tissue and release of calcium into the blood. Bone resorption can weaken the bones and increase the risk of pathologic fractures, which are fractures that occur due to disease or injury to the bone.
Choice C: Fluid retention. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Fluid retention is excess fluid accumulation in the body, which can be caused by disorders of the heart, kidney, liver, or lymphatic system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Choice D: Impaired skin integrity. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Impaired skin integrity is damage or loss of skin tissue, which can be caused by trauma, infection, inflammation, or pressure. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Correct Answer is D
Explanation
Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.
Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.
Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.
Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.
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