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?
Jaundice
Ascites
Spider angiomas
Hepatic encephalopathy
The Correct Answer is C
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.
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Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
Jaundice refers to the yellowing of the skin and eyes and is caused by the accumulation of bilirubin in the blood. While jaundice can be associated with liver cirrhosis, it does not describe the symptom of severe itching.
Pruritus refers to severe itching of the skin, which can occur in clients with liver cirrhosis due to the buildup of bile acids in the blood and skin. Elevated levels of bile acids can irritate the skin, leading to itching.
Hematemesis refers to vomiting of blood and is not related to the symptom of severe itching.
Ascites is the accumulation of fluid in the abdominal cavity and is not related to the symptom of severe itching.
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