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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Related Questions
Correct Answer is C
Explanation
A) Restricting fluid intake is not appropriate for managing ascites in clients with liver cirrhosis. Ascites occurs due to fluid accumulation in the peritoneal cavity and is not primarily influenced by oral fluid intake.
B) Encouraging a high-sodium diet is contraindicated in clients with ascites. High sodium intake can exacerbate fluid retention and worsen ascites. Instead, clients with ascites should be on a low-sodium diet to reduce fluid accumulation.
C) In a client with liver cirrhosis experiencing fluid retention and abdominal distension due to ascites, paracentesis is an essential intervention to drain the accumulated ascitic fluid from the abdominal cavity. Paracentesis helps to relieve discomfort, improve respiratory function, and reduce intra-abdominal pressure.
D) Diuretics are used in the management of ascites to promote urine output and reduce fluid retention. However, paracentesis is a more immediate intervention for relieving discomfort and removing a large volume of ascitic fluid.
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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