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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Your baby needs to suck on a pacifier.": While non-nutritive sucking on a pacifier can sometimes soothe a fussy baby, it is not the first recommendation, especially for a newborn who is establishing breastfeeding. Early introduction of pacifiers can interfere with successful breastfeeding due to nipple confusion.
B. "Breastfed babies are usually fussy from swallowing too much air during feedings.": Although some air swallowing can occur, especially if the latch is poor, this is not typically the primary reason for persistent crying. Addressing crying with soothing techniques like swaddling is a more immediate and supportive intervention for the parent.
C. "Swaddling your baby snugly in a blanket might help soothe her.": Swaddling provides warmth, security, and a sense of being back in the womb, which can calm a newborn effectively. It reduces the startle reflex and helps regulate the baby's nervous system, often resulting in decreased crying and improved comfort.
D. "Breastfed babies often need to be supplemented with formula.": Routine supplementation with formula is not recommended for healthy breastfed newborns unless there are clear medical indications. Promoting exclusive breastfeeding supports optimal nutrition, bonding, and gut health in the early postpartum period.
Correct Answer is D
Explanation
A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.
B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.
C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.
D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.
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