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

Rationale:

A. Triiodothyronine: Triiodothyronine (T3) measures thyroid function and is not related to anticoagulation therapy. It is important for evaluating thyroid disorders but has no role in monitoring the effects of warfarin.

B. Arterial blood gases: Arterial blood gases (ABGs) assess oxygenation, ventilation, and acid-base balance, not anticoagulation status. ABGs are not used to monitor warfarin therapy.

C. Serum potassium: Serum potassium levels are crucial for cardiac and muscle function but are not affected directly by warfarin use. Potassium monitoring is more critical with diuretics or certain cardiac medications, not anticoagulants like warfarin.

D. Prothrombin time: Prothrombin time (PT) measures how long it takes blood to clot and is directly affected by warfarin therapy. Monitoring PT (and the related INR) ensures that the warfarin dose maintains therapeutic anticoagulation without causing excessive bleeding.

A. Anuria B. A 7% weight loss from baseline C. Нуреrpnea D. Lethargy

Correct Answer is B

Explanation

A. Anuria: Anuria, or the absence of urine output, indicates severe dehydration or acute renal failure rather than moderate dehydration. Moderate dehydration usually presents with decreased but not absent urine output, as the body still tries to conserve fluids.

B. A 7% weight loss from baseline: A weight loss of 6% to 9% of body weight is consistent with moderate dehydration in infants and children. This measurable sign is a critical and objective indicator used to assess the severity of dehydration, particularly following prolonged vomiting or diarrhea.

C. Hyperpnea: Hyperpnea, or abnormally deep and rapid breathing, can be seen in cases of severe dehydration or metabolic acidosis. It is not a classic finding of moderate dehydration, where respiratory patterns are usually normal or only mildly affected.

D. Lethargy: Lethargy typically suggests severe dehydration rather than moderate. In moderate dehydration, the infant may be irritable or thirsty but usually maintains normal mental status without profound decreases in responsiveness or alertness.

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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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Explanation

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