A nurse is caring for a client who is postoperative and has a history of Addison’s disease. For which of the following manifestations should the nurse monitor?

Choice A: Weak pulse. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. A weak pulse may indicate hypovolemia, shock, or cardiac dysfunction, but it is not directly related to liver disease.

Choice B: Dark colored stools. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Dark colored stools may indicate bleeding in the upper gastrointestinal tract, such as from esophageal varices or peptic ulcers, but they are not specific to liver disease.

Choice C: Spider angioma. This is a manifestation that the nurse should expect to find in a client who has advanced cirrhosis, which is a chronic liver disease that causes scarring and impaired liver function. Spider angioma is a type of vascular lesion that appears as a red spot with radiating branches on the skin, usually on the face, neck, chest, or upper arms. It is caused by increased estrogen levels due to reduced liver metabolism of hormones.

Choice D: Increased body hair. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Increased body hair may indicate hypertrichosis, which is excessive hair growth due to genetic, hormonal, or metabolic factors, but it is not related to liver disease.

Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, fluid imbalance, or shock, but these are not as urgent as relieving the client’s pain.

Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their fluid status and nutritional needs, but this can be done after addressing the client’s pain.

Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and affect their quality of life.

Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.