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 B
Explanation
Choice A rationale
While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.
Choice B rationale
Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.
Choice C rationale
Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.
Choice D rationale
Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.
Correct Answer is B
Explanation
Choice A rationale
Administering diphenhydramine with food does not specifically address the adverse effect of dry mouth. While taking the medication with food can help reduce gastrointestinal side effects, it does not alleviate dry mouth.
Choice B rationale
Chewing on sugarless gum or sucking on hard candies can help stimulate saliva production and alleviate dry mouth. This is an effective and simple measure to manage the adverse effect of dry mouth associated with diphenhydramine.
Choice C rationale
Placing a humidifier at the bedside can help maintain moisture in the air, but it is not the most effective measure for managing dry mouth. Chewing gum or sucking on candies directly stimulates saliva production, providing more immediate relief.
Choice D rationale
Discontinuing the medication and notifying the provider is not necessary for managing dry mouth. Dry mouth is a common and manageable side effect of diphenhydramine. Simple measures like chewing gum or sucking on candies are usually sufficient to alleviate this symptom
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