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

Choice A: “Monitor blood glucose levels every 4 hours.” This is the priority action for the nurse to recommend to the client because it will help them detect and prevent hyperglycemia or hypoglycemia, which can lead to serious complications such as diabetic ketoacidosis or cerebral edema.

Choice B: “Consume 15 grams of carbohydrates every 1 to 2 hours.” This is an important action for the nurse to recommend to the client, but not the priority. The client should consume carbohydrates to prevent hypoglycemia, especially if they have nausea, vomiting, or diarrhea, but this should be done after monitoring their blood glucose levels.

Choice C: “Drink 8 ounces of fluid every hour while awake.” This is a necessary action for the nurse to recommend to the client, but not the priority. The client should drink fluids to prevent dehydration and electrolyte imbalance, which can worsen hyperglycemia, but this should be done after monitoring their blood glucose levels.

Choice D: “Take the usual dosage of insulin.” This is a required action for the nurse to recommend to the client, but not the priority. The client should take their insulin as prescribed to control their blood glucose levels, but this should be done after monitoring their blood glucose levels and adjusting the dosage if needed.

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.