The nurse is assessing a client with suspected hepatitis. Which finding is most indicative of this condition?
Anorexia
Clay-colored stools
Brown, foamy urine
Hematemesis
The Correct Answer is B
Choice A reason: Anorexia is common in hepatitis due to systemic inflammation but is nonspecific, occurring in many conditions. Clay-colored stools directly indicate impaired bile excretion from liver dysfunction, a hallmark of hepatitis, making it a more diagnostic finding.
Choice B reason: Clay-colored stools are highly indicative of hepatitis, as liver inflammation impairs bile production or excretion, reducing bilirubin in feces. This causes pale stools, reflecting hepatic dysfunction, making it a key finding to confirm hepatitis over nonspecific symptoms like anorexia.
Choice C reason: Brown, foamy urine is not typical of hepatitis. Dark urine from bilirubinuria may occur, but foamy urine suggests proteinuria, unrelated to liver dysfunction. Clay-colored stools are more specific, indicating bile flow obstruction, a direct sign of hepatitis pathology.
Choice D reason: Hematemesis indicates gastrointestinal bleeding, not a primary hepatitis feature. While advanced liver disease may cause variceal bleeding, clay-colored stools are an earlier, more specific sign of hepatitis-related bile impairment, making them the priority finding in acute cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Increasing iron-rich foods (e.g., red meat, spinach) corrects anemia by boosting hemoglobin synthesis, as iron is essential for red blood cell production. This addresses the underlying deficiency, improving oxygen transport, making it the priority dietary recommendation for anemia management.
Choice B reason: Limiting vitamin C is incorrect, as it enhances iron absorption, aiding anemia correction. Iron-rich foods are the priority, as they directly supply the deficient nutrient, improving hemoglobin levels, making vitamin C restriction counterproductive to effective anemia treatment.
Choice C reason: Restricting green leafy vegetables, which are iron-rich, worsens anemia. These foods (e.g., spinach) provide dietary iron, essential for hemoglobin synthesis. Increasing iron intake is the priority, as it corrects the deficiency, making vegetable restriction inappropriate for anemia.
Choice D reason: Avoiding whole grains is irrelevant, as they provide nutrients supporting overall health. Iron-rich foods directly address anemia by supplying iron for red blood cell production, making them the priority dietary recommendation over grain restrictions, which do not impact anemia correction.
Correct Answer is A
Explanation
Choice A reason: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.
Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.
Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.
Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.
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