A nurse is collecting data from a client who has cirrhosis of the liver. Which of the following findings should the nurse identify as the priority?

Clay-colored stools

Confusion

Spider angiomas

Jaundice

Answer and Explanation

The Correct Answer is B

A. Clay-colored stools: Clay-colored stools indicate a lack of bile flow due to liver dysfunction, which is expected in cirrhosis. While concerning, it is not the most urgent finding compared to signs indicating acute neurological compromise.

B. Confusion: Confusion suggests hepatic encephalopathy, a serious complication of cirrhosis resulting from the buildup of toxins like ammonia in the bloodstream. It indicates potential cerebral impairment and requires immediate provider notification and intervention to prevent progression to coma.

C. Spider angiomas: Spider angiomas are small, dilated blood vessels visible on the skin, commonly seen in cirrhosis due to hormonal changes and altered vascular dynamics. They are a chronic sign of liver disease and do not represent an immediate threat.

D. Jaundice: Jaundice results from elevated bilirubin levels due to impaired liver function. While jaundice signals worsening liver disease, it develops gradually and is less immediately life-threatening than the onset of neurological symptoms like confusion.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.

B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL) B. A client who has a spinal cord injury and needs a dressing change C. A client who has a temperature of 38.4° C (101.1 F) and appears confused D. A client who had a hip arthroplasty and is requesting pain medication

Correct Answer is C

Explanation

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

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A nurse is collecting data from a client who has cirrhosis of the liver. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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