A nurse is collecting data from a client who has cirrhosis of the liver. Which of the following findings should the nurse identify as the priority?
Clay-colored stools
Confusion
Spider angiomas
Jaundice
The Correct Answer is B
A. Clay-colored stools: Clay-colored stools indicate a lack of bile flow due to liver dysfunction, which is expected in cirrhosis. While concerning, it is not the most urgent finding compared to signs indicating acute neurological compromise.
B. Confusion: Confusion suggests hepatic encephalopathy, a serious complication of cirrhosis resulting from the buildup of toxins like ammonia in the bloodstream. It indicates potential cerebral impairment and requires immediate provider notification and intervention to prevent progression to coma.
C. Spider angiomas: Spider angiomas are small, dilated blood vessels visible on the skin, commonly seen in cirrhosis due to hormonal changes and altered vascular dynamics. They are a chronic sign of liver disease and do not represent an immediate threat.
D. Jaundice: Jaundice results from elevated bilirubin levels due to impaired liver function. While jaundice signals worsening liver disease, it develops gradually and is less immediately life-threatening than the onset of neurological symptoms like confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Acute hemolytic: An acute hemolytic reaction typically presents with symptoms like fever, chills, back pain, hypotension, and hematuria. It is caused by the recipient’s immune system attacking incompatible donor red blood cells, not primarily by urticaria and wheezing.
B. Anaphylactic: An anaphylactic reaction is a severe allergic response to blood transfusion and is characterized by symptoms such as urticaria (hives), wheezing, hypotension, and respiratory distress. It requires immediate intervention, including stopping the transfusion and administering emergency medications.
C. Febrile: A febrile reaction is usually marked by fever, chills, and headache during or shortly after a transfusion. It does not typically involve wheezing or significant allergic skin reactions like urticaria.
D. Circulatory overload: Circulatory overload occurs when too much fluid is administered too quickly, leading to symptoms like dyspnea, cough, and pulmonary edema. While it involves respiratory symptoms, it is not associated with urticaria or allergic reactions.
Correct Answer is B
Explanation
A. Psychologist: A psychologist focuses on mental health assessment and therapy rather than medication management. While they are essential for emotional and psychological support, they are not trained to evaluate or address potential drug interactions in a client's medication regimen.
B. Advanced practice nurse: An advanced practice nurse, such as a nurse practitioner, has the education and authority to assess medication regimens, recognize potential drug interactions, and make adjustments or recommendations. They are well-qualified to manage complex medication issues and collaborate closely with prescribing providers.
C. Patient care technician: Patient care technicians assist with basic care activities such as hygiene, mobility, and vital signs monitoring but do not have the education or licensure required to evaluate medications. They are not involved in clinical decision-making regarding pharmacologic therapy.
D. Social worker: A social worker provides resources for social support, financial assistance, and counseling, but medication management is outside their scope of practice. They are valuable for holistic care but not for assessing or managing drug interactions specifically.
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