A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?
Weak pulse
Dark colored stools
Spider angioma
Increased body hair
The Correct Answer is C
Choice A: Weak pulse. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. A weak pulse may indicate hypovolemia, shock, or cardiac dysfunction, but it is not directly related to liver disease.
Choice B: Dark colored stools. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Dark colored stools may indicate bleeding in the upper gastrointestinal tract, such as from esophageal varices or peptic ulcers, but they are not specific to liver disease.
Choice C: Spider angioma. This is a manifestation that the nurse should expect to find in a client who has advanced cirrhosis, which is a chronic liver disease that causes scarring and impaired liver function. Spider angioma is a type of vascular lesion that appears as a red spot with radiating branches on the skin, usually on the face, neck, chest, or upper arms. It is caused by increased estrogen levels due to reduced liver metabolism of hormones.
Choice D: Increased body hair. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Increased body hair may indicate hypertrichosis, which is excessive hair growth due to genetic, hormonal, or metabolic factors, but it is not related to liver disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Determine the client’s calcium level. This is the priority action for the nurse to take because the client might have hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia can occur after a thyroidectomy due to accidental removal or damage of the parathyroid glands, which regulate calcium levels. Hypocalcemia can cause muscle spasms, tetany, paresthesia, and seizures.
Choice B: Give the client an oral potassium supplement. This is not an appropriate action for the nurse to take because the client might have hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can also occur after a thyroidectomy due to damage to the adrenal glands, which regulate potassium levels. Hyperkalemia can cause muscle weakness, arrhythmias, and cardiac arrest.
Choice C: Administer intravenous normal saline solution. This is not a necessary action for the nurse to take because the client does not have signs of dehydration or fluid imbalance. Normal saline solution does not affect calcium or potassium levels.
Choice D: Monitor the client’s peripheral pulses. This is an important action for the nurse to take, but not the priority. The nurse should monitor the client’s peripheral pulses for signs of decreased perfusion or ischemia, which can result from hypocalcemia or hyperkalemia affecting the cardiac function. However, this should be done after determining the client’s calcium level and correcting it if needed.
Correct Answer is B
Explanation
Choice A: Upper left quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper left quadrant of the abdomen contains organs such as the stomach, spleen, pancreas, and part of the colon. Abdominal pain in this area can indicate conditions such as gastritis, peptic ulcer, pancreatitis, splenomegaly, or colon cancer.
Choice B: Lower left quadrant. This is the location where the nurse should expect the client to report abdominal pain who has diverticular disease, which is a condition that involves the formation of pouches or sacs in the wall of the colon. These pouches or sacs are called diverticula, and they can become inflamed or infected, causing diverticulitis. Diverticulitis can cause abdominal pain, fever, nausea, vomiting, and changes in bowel habits. The most common site of diverticula formation and diverticulitis is the sigmoid colon, which is located in the lower left quadrant of the abdomen.
Choice C: Upper right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper right quadrant of the abdomen contains organs such as the liver, gallbladder, duodenum, and part of the colon. Abdominal pain in this area can indicate conditions such as hepatitis, cholecystitis, duodenal ulcer, or colon cancer.
Choice D: Lower right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The lower right quadrant of the abdomen contains organs such as the appendix, cecum, and part of the colon. Abdominal pain in this area can indicate conditions such as appendicitis, Crohn’s disease, or colon cancer.
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