A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
Blood in the urine
Spider angiomas
Tarry stools
Moist skin
The Correct Answer is B
Choice A reason:
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
Choice B reason:
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis.
They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
Choice C reason:
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
Choice D reason:
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
After a Billroth I procedure, where the stomach is anastomosed directly to the duodenum, some patients may experience diarrhea and feelings of fullness due to the direct passage of food into the small intestine without the buffering effect of the pyloric valve.
Choice B reason:
Gastric reflux and belching are not typically associated with a Billroth I procedure.
Choice C reason:
Persistent feelings of hunger and thirst are not common adverse effects associated specifically with a Billroth I procedure.
Choice D reason:
Constipation or bowel incontinence are not typically associated with a Billroth I procedure, as this surgery involves the upper gastrointestinal tract.
Correct Answer is D
Explanation
- A: This response minimizes the client's feelings and may make them feel unheard. It's important for healthcare providers to acknowledge a patient's feelings and provide reassurance in a more empathetic manner.
- B: This response delays addressing the client's concerns and may increase his anxiety. Consent is important, but it should not be a barrier to discussing care and addressing concerns.
- C: This response is factual but does not address the client's immediate concern about pain. It's crucial to address the client's fears directly rather than deflecting to the procedure's necessity.
- D: This response directly addresses the client's concern about pain by informing him of the sedative, which is a common practice to reduce discomfort during a colonoscopy. It provides reassurance and factual information about the procedure's process.
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