Which assessment findings are consistent with cirrhosis? Select all that apply.
Jaundice
Spider angiomas
Lethargic
Apical pulse regular with S1, S2
Abdomen moderately distended
Dark amber urine
Peripheral pulses are palpable
3+ pitting edema
Correct Answer : A,B,E,F,H
Choice A reason: Jaundice is a common finding in cirrhosis due to impaired liver function, which leads to the accumulation of bilirubin in the blood. This causes the skin and the whites of the eyes to turn yellow.
Choice B reason: Spider angiomas are dilated blood vessels that appear on the skin and are often seen in patients with cirrhosis. They are caused by increased estrogen levels due to impaired liver function.
Choice C reason: Lethargy is a symptom of cirrhosis as the liver's ability to detoxify the blood is compromised, leading to fatigue and weakness.
Choice D reason: An apical pulse regular with S1, S2 is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice E reason: Abdomen moderately distended is consistent with cirrhosis due to the accumulation of fluid in the abdominal cavity (ascites), which is a common complication of advanced liver disease.
Choice F reason: Dark amber urine is a sign of cirrhosis as the liver's ability to process bilirubin is impaired, leading to the excretion of conjugated bilirubin in the urine, which gives it a dark color.
Choice G reason: Peripheral pulses are palpable is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice H reason: 3+ pitting edema is consistent with cirrhosis due to the retention of sodium and water, leading to swelling in the lower extremities.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.
Correct Answer is ["A","B","E","F","H"]
Explanation
Choice A reason: Jaundice is a common finding in cirrhosis due to impaired liver function, which leads to the accumulation of bilirubin in the blood. This causes the skin and the whites of the eyes to turn yellow.
Choice B reason: Spider angiomas are dilated blood vessels that appear on the skin and are often seen in patients with cirrhosis. They are caused by increased estrogen levels due to impaired liver function.
Choice C reason: Lethargy is a symptom of cirrhosis as the liver's ability to detoxify the blood is compromised, leading to fatigue and weakness.
Choice D reason: An apical pulse regular with S1, S2 is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice E reason: Abdomen moderately distended is consistent with cirrhosis due to the accumulation of fluid in the abdominal cavity (ascites), which is a common complication of advanced liver disease.
Choice F reason: Dark amber urine is a sign of cirrhosis as the liver's ability to process bilirubin is impaired, leading to the excretion of conjugated bilirubin in the urine, which gives it a dark color.
Choice G reason: Peripheral pulses are palpable is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice H reason: 3+ pitting edema is consistent with cirrhosis due to the retention of sodium and water, leading to swelling in the lower extremities.
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