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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Correct Answer is D

Explanation

A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.

B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.

C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.

D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.

A. Decreased bowel sounds B. Urine output of 360 mL/12 hr C. Blood pressure of 100/74 mm Hg D. Distended neck veins

Correct Answer is D

Explanation

A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.

B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.

C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.

D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.

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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?

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