A nurse is assessing a client who has cirrhosis.
Which of the following is an expected finding for this client?
Moist skin.
Blood in the urine.
Spider angiomas.
Tarry stools.
The Correct Answer is C
Choice A rationale
Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.
Choice B rationale
Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.
Choice C rationale
Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.
Choice D rationale
Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.
Choice B rationale
The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.
Choice C rationale
Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.
Choice D rationale
Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.
Correct Answer is C
Explanation
Choice A rationale
Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.
Choice B rationale
Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.
Choice C rationale
A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.
Choice D rationale
A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.
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