A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?

Administer pain medication to alleviate discomfort.

Document the findings and continue monitoring the client.

Obtain an order for a liver biopsy to assess liver function.

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is D

A) Pain medication is not appropriate for managing altered mental status and confusion. The priority is to identify and address the underlying cause of the client's symptoms.

B) While documentation and ongoing monitoring are important, the priority is to take immediate action when the client is exhibiting signs of altered mental status. The nurse should promptly notify the healthcare provider for further evaluation and intervention.

C) A liver biopsy is a diagnostic procedure that provides information about the degree of liver damage and fibrosis. However, it is not the first action to take when the client is experiencing altered mental status and confusion. Immediate notification of the healthcare provider is the priority in this situation.

D) Altered mental status and confusion in a client with liver cirrhosis can indicate hepatic encephalopathy, a serious complication of advanced liver disease. Hepatic encephalopathy results from the accumulation of toxic substances in the blood due to impaired liver function. The nurse should prioritize notifying the healthcare provider immediately to initiate appropriate interventions and prevent further deterioration of the client's condition.

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Correct Answer is C

Explanation

A) Jaundice (yellowing of the skin and eyes) typically appears later in the course of liver cirrhosis and is usually associated with more advanced liver damage.

B) Ascites, the accumulation of fluid in the abdominal cavity, is a later manifestation of liver cirrhosis and usually occurs after significant liver damage has occurred.

C) Spider angiomas, also known as spider nevi or spider telangiectasias, are dilated blood vessels that appear as small red spots with tiny radiating legs. They are a common early sign of liver cirrhosis and result from increased pressure in the superficial blood vessels due to impaired liver function. Spider angiomas are often found on the face, neck, upper trunk, and arms.

D) Hepatic encephalopathy, a neuropsychiatric complication of advanced liver disease, is also a later manifestation of liver cirrhosis and is not an early sign of the condition.

A. Hepatocellular carcinoma B. Portal hypertension C. Hepatic encephalopathy D. Hepatopulmonary syndrome

Correct Answer is D

Explanation

A) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not typically associated with difficulty sleeping or shortness of breath.

B) Portal hypertension, a common complication of liver cirrhosis, can lead to the development of ascites and esophageal varices, among other manifestations. It is not the likely cause of the client's difficulty sleeping and shortness of breath.

C) Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease and is not associated with difficulty sleeping or shortness of breath.

D) Hepatopulmonary syndrome is a complication of liver cirrhosis characterized by the development of pulmonary vascular dilation and arteriovenous shunting. This results in impaired oxygenation of blood, leading to difficulty breathing (dyspnea), especially while lying down (orthopnea). Clients with hepatopulmonary syndrome often experience frequent awakenings due to shortness of breath during sleep.

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A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with suspected liver cirrhosis. Which clinical manifestation should the nurse expect to find as an early sign of the condition?

Correct Answer is C

Explanation

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?

Correct Answer is D

Explanation

A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?

A nurse is reviewing the laboratory results of a client suspected to have liver cirrhosis. Which finding should the nurse expect to be elevated, indicating impaired liver function?

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A nurse is providing community education on the risk factors for liver cirrhosis. Which risk factor should the nurse emphasize as the leading cause of liver cirrhosis?

A client with liver cirrhosis complains of severe itching. Which term should the nurse use to document this symptom?

A client with suspected liver cirrhosis is scheduled for a diagnostic imaging test. Which imaging modality is commonly used to assess the liver's size, shape, and structure in clients with cirrhosis?

A client with liver cirrhosis is experiencing fluid retention and abdominal distension due to ascites. Which nursing intervention is essential to manage this complication?

A client with liver cirrhosis is found to have elevated iron levels in their blood. Which genetic disorder should the nurse suspect as a possible cause of these findings?