A nurse is assessing a client who has cirrhosis.

Which of the following findings is the priority for the nurse to report?

Distended abdomen.

Clay-colored stools.

Platelets 70,000/mm.

Alkaline phosphatase 125 units/L.

Answer and Explanation

The Correct Answer is C

Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.

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Correct Answer is B

Explanation

Pitting edema is a common and obvious symptom of right-sided heart failure.

This occurs when fluid retention causes swelling in the lower limbs and sometimes the abdomen.
Choice A is incorrect because poor skin turgor is not a common symptom of right-sided heart failure.
Choice C is incorrect because oliguria, or decreased urine output, is not a common symptom of right-sided heart failure.
Choice D is incorrect because S4 galloping heart sounds are not a common symptom of right-sided heart failure.

A. "What is meant by the saying, 'Don't beat around the bush?". B. "Can you tell me the state where you were born?". C. "Can you count backward from 100 in intervals of 7?". D. "What do you understand about your condition?".

Correct Answer is A

Explanation

Asking the client “What is meant by the saying, ‘Don’t beat around the bush?’” is a way to assess the client’s abstract thinking.
Abstract thinking involves understanding concepts and ideas that are not concrete or tangible, such as interpreting figurative language or proverbs.
Choice B is incorrect because it assesses the client’s memory rather than their abstract thinking.
Choice C is incorrect because it assesses the client’s attention and concentration rather than their abstract thinking.
Choice D is incorrect because it assesses the client’s insight and understanding of their condition rather than their abstract thinking.

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A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking?

Correct Answer is A

Explanation

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A nurse is assessing a client who has cirrhosis.

Which of the following findings is the priority for the nurse to report?