A nurse is assessing a client diagnosed with cirrhosis.
Which of the following manifestations should the nurse expect?
Tarry stools.
Spider angiomas.
Moist skin.
Blood in the urine.
The Correct Answer is B
Choice A rationale
Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.
Choice B rationale
Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.
Choice C rationale
Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.
Choice D rationale
Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.
Choice B rationale
This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.
Choice C rationale
This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.
Choice D rationale
While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.
Correct Answer is D
Explanation
Choice A rationale
Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.
Choice B rationale
Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.
Choice C rationale
Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.
Choice D rationale
Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.
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