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 C
Explanation
Choice A rationale
Restricting outdoor activity to 1 hour per day is not necessary for patients with sickle cell anemia. While strenuous exercise and overexertion should be avoided, regular moderate exercise is beneficial and helps to promote good overall health.
Choice B rationale
Applying cold compresses when the child expresses pain is not recommended. Cold can lead to vasoconstriction, which can trigger a sickle cell crisis. Instead, warm compresses are often used to help increase circulation and reduce pain.
Choice C rationale
Drinking fluids multiple times every day is crucial. Hydration helps to keep the blood diluted and reduces the chances of a sickle cell crisis. Dehydration can increase the risk of a sickle cell crisis.
Choice D rationale
Monitoring temperature daily is not specifically required for patients with sickle cell anemia. However, any signs of infection, such as fever, should be reported to a healthcare provider immediately, as infection can trigger a sickle cell crisis.
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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