A nurse is assessing a client with liver disease who presents with abdominal distention and visible skin changes. Which of the following findings should the nurse prioritize as indicative of liver disease complications during the abdominal inspection?
Dilated abdominal veins (caput medusae)
Pink or silver stretch marks on the abdomen
Generalized rash on the abdomen
Purple striae on the abdomen
The Correct Answer is A
Choice A reason: Caput medusae refers to the visible, dilated, and tortuous subcutaneous veins radiating from the umbilicus. This is a classic clinical manifestation of portal hypertension secondary to cirrhosis, where portal blood is redirected through collateral venous pathways, specifically the paraumbilical veins, indicating severe, advanced hepatic compromise.
Choice B reason: Pink or silver striae, also known as striae albicantes, are common skin findings resulting from the stretching of the dermis during pregnancy or rapid weight fluctuations. They are generally considered benign and do not provide specific diagnostic information regarding hepatic dysfunction or the presence of underlying liver disease.
Choice C reason: A generalized abdominal rash is a non-specific dermatological finding that could be attributed to a variety of etiologies, including allergic reactions, contact dermatitis, or localized infections. It does not possess the clinical specificity required to diagnose or identify complications related to chronic liver disease or portal hypertension.
Choice D reason: Purple striae, often referred to as striae rubrae, are frequently associated with excessive levels of endogenous or exogenous glucocorticoids, as seen in Cushing syndrome. While they indicate physical stretching, they are not a diagnostic indicator of cirrhosis, portal hypertension, or other primary complications of advanced liver disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The aortic valve is auscultated at the second intercostal space along the right sternal border. This location is anatomically optimized to capture sounds generated by blood flow exiting the left ventricle through the aortic valve into the systemic circulation, rather than the mitral valve site.
Choice B reason: The mitral valve is anatomically located at the cardiac apex. Auscultation at the fifth intercostal space along the left midclavicular line allows the stethoscope to be placed directly over this point of maximal impulse, where the mitral valve's S1 closure is most distinctively heard during the cardiac cycle.
Choice C reason: The pulmonic valve is auscultated at the second intercostal space along the left sternal border. This position is specific to monitoring the closure of the semilunar pulmonic valve and is distinct from the apical position used for the mitral valve.
Choice D reason: Erb's Point is situated at the third intercostal space along the left sternal border. This is a common location where sounds from both the aortic and pulmonic valves are heard with relatively equal intensity, facilitating the detection of murmurs, but it is not the anatomical site for the mitral valve.
Correct Answer is B
Explanation
Choice A reason: While the cuff must be placed above the antecubital space, a fixed 5 cm distance is not the universal standard for all arm lengths. The priority is to ensure the bladder of the cuff is centered over the brachial artery and does not interfere with the placement of the stethoscope or sensor.
Choice B reason: The artery indicator (often an arrow on the cuff) must be correctly aligned with the anatomical path of the brachial artery. Misalignment can lead to inaccurate pressure readings, as the sensor or stethoscope will not be directly over the point of pulse detection, resulting in an erroneous systolic or diastolic value.
Choice C reason: Elevating the arm above the level of the heart will produce a falsely low blood pressure reading due to the effects of gravity on venous return and hydrostatic pressure. The arm must be supported and positioned at the level of the heart to ensure an accurate measurement that reflects central arterial pressure.
Choice D reason: Selecting a cuff that covers only 50% of the upper arm is incorrect; a cuff that is too small (narrow) will lead to a falsely high blood pressure reading. The standard requirement is for the cuff bladder to cover at least 80% of the arm circumference and 40% of the arm length.
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