A nurse is caring for a client who has a new diagnosis of liver disease. Which of the following manifestations should the nurse expect?

Night sweats

Acanthosis nigricans

Hemosiderin staining

Pruritus

Answer and Explanation

The Correct Answer is D

Choice A Reason: Night sweats

Night sweats are not typically associated with liver disease. They are more commonly linked to conditions such as infections, hormonal imbalances, or certain cancers1. While liver disease can cause a variety of symptoms, night sweats are not a primary manifestation.

Choice B Reason: Acanthosis nigricans

Acanthosis nigricans is characterized by dark, velvety patches of skin, usually in body folds and creases. It is often associated with insulin resistance, obesity, and certain endocrine disorders. It is not a common manifestation of liver disease.

Choice C Reason: Hemosiderin staining

Hemosiderin staining refers to the deposition of iron in the skin, which can cause a brownish discoloration. This condition is more commonly associated with chronic venous insufficiency or hemochromatosis, a genetic disorder that causes iron overload. It is not a typical symptom of liver disease.

Choice D Reason: Pruritus

Pruritus, or itching, is a common symptom of liver disease. It is often caused by the accumulation of bile salts in the skin due to impaired bile flow, a condition known as cholestasis. This symptom can be particularly distressing for patients and is a significant indicator of liver dysfunction.

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Correct Answer is C

Explanation

Choice A Reason:

Removing the protective gown before removing gloves is incorrect. The correct procedure is to remove gloves first, followed by the gown, to prevent contamination from the gown to the hands.

Choice B Reason:

Using an electronic thermometer is not recommended for clients with Clostridium difficile. Disposable thermometers or dedicated equipment should be used to prevent cross-contamination.

Choice C Reason:

This is the correct answer. The protective gown should be removed before leaving the client’s room to prevent the spread of Clostridium difficile spores to other areas of the healthcare facility. Proper removal and disposal of PPE are crucial in infection control.

Choice D Reason:

Shaking bed linens is incorrect as it can aerosolize Clostridium difficile spores, increasing the risk of spreading the infection. Linens should be carefully handled and placed in a linen bag without shaking.

A. “You should expect your stoma to be a purple color.” B. “Your colostomy will not produce formed stool.” C. “The end of the stoma will be painful after this procedure.” D. “You will have a stoma in your left lower abdomen.”

Correct Answer is D

Explanation

Choice A Reason:

A healthy stoma should be pink or red, not purple. A purple stoma could indicate compromised blood flow and requires immediate medical attention.

Choice B Reason:

A sigmoid colostomy typically produces formed stool because it is located in the lower part of the colon, where water absorption occurs.

Choice C Reason:

The stoma itself should not be painful after the procedure. Pain may indicate complications such as infection or improper stoma care.

Choice D Reason:

This is the correct answer. A sigmoid colostomy is usually located in the left lower abdomen, as this is where the sigmoid colon is situated.

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A nurse is caring for a client who has a new diagnosis of liver disease. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

Correct Answer is D

Explanation

A nurse is teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include?

A nurse is providing education to a client who needs a cholecystectomy due to a build-up of calculi or gallstones. Which of the following is the best response from the nurse to explain what caused this problem?

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client’s discomfort?

A nurse is teaching a newly licensed nurse about wearing medical masks. Which of the following statements should the nurse include?

A nurse is preparing discharge instructions for a client who has been treated for acute pancreatitis. Which of the following statements is important to include in the information?

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A nurse is caring for a client who has a cerebral aneurysm. In the event of a ruptured cerebral aneurysm, which of the following manifestations would be present in the client? (Select All that Apply)

A nurse is teaching a client who has constipation. Which of the following statements should the nurse include?