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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?

A.

Clay-colored stools

B.

Confusion

C.

Spider angiomas

D.

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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Related Questions

Correct Answer is A

Explanation

  • Allergies: The client has a documented allergy to penicillin, and cefazolin is a first-generation cephalosporin. Cephalosporins have a similar beta-lactam structure to penicillins, and there is a potential risk of cross-reactivity. Administering cefazolin without provider clearance could result in a severe allergic reaction or anaphylaxis.
  • Temperature: Although the client's temperature is elevated at 39.3° C (102.8° F), this is an expected finding in pneumonia and does not need to be reported before antibiotic administration. In fact, treating the infection may help reduce the fever.
  • Chest x-ray: The chest x-ray showing left lower lobe density is consistent with a diagnosis of pneumonia and supports the need for antibiotic treatment. This finding confirms the infection in the lungs and guides the choice of antibiotic therapy. It is not a reason to withhold the prescribed medication but rather a justification for it.
  • WBC count: The client’s WBC count is elevated at 16,000/mm³, which is typical in bacterial infections like pneumonia. It reflects the body's immune response and further supports the need for antibiotics rather than delaying them.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

  • Placenta previa: Placenta previa occurs later in pregnancy and is characterized by painless bright red vaginal bleeding without abdominal tenderness. The client is only 6 weeks pregnant, and placenta previa is not a concern this early in gestation.
  • abruptio placentae: Abruptio placentae involves painful bleeding and a rigid uterus, usually occurring after 20 weeks' gestation. The client’s gestational age and presenting symptoms are more consistent with an early pregnancy complication rather than abruptio placentae.
  • ectopic pregnancy: This occurs when a fertilized egg implants outside the uterus. The client’s missed period, positive pregnancy test, right lower quadrant tenderness, and dark red vaginal spotting are classic signs of ectopic pregnancy. Ectopic pregnancy is a life-threatening emergency if rupture occurs, requiring prompt identification and management.
  • acute asthma attack: While the client has a history of asthma and slight inspiratory wheezing, her respiratory status is stable with normal oxygen saturation and no signs of acute respiratory distress. Therefore, an asthma attack is not the primary concern.
  • pyelonephritis: Pyelonephritis typically presents with fever, chills, flank pain, and urinary symptoms. The client’s presentation of right lower quadrant tenderness and vaginal spotting does not align with the typical findings of pyelonephritis.
  • respiratory rate: The client’s respiratory rate is normal at 16/min, indicating stable respiratory function. Respiratory rate does not explain the primary concern related to abdominal pain and vaginal bleeding.
  • history of regular menstrual period: While this supports that the client is late in her cycle, it is not the most direct or critical finding pointing toward the diagnosis. The focus should be on current clinical signs like abdominal tenderness.
  • temperature: The client’s temperature is within normal range at 37.3°C (99.1°F), making infection less likely and not the primary concern related to her current symptoms.
  • right lower quadrant abdominal tenderness: Localized tenderness in the right lower quadrant combined with vaginal spotting strongly suggests an ectopic pregnancy. This is a hallmark finding that supports the diagnosis as the growing embryo can cause irritation, stretching, or rupture of the fallopian tube.
  • hyperactive bowel sounds: Hyperactive bowel sounds are nonspecific and can occur due to anxiety, mild gastrointestinal upset, or pain, but they are not diagnostic for ectopic pregnancy. The abdominal tenderness is the more significant finding.

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