The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.)
Jaundice
Clay-colored stools
Icterus
Ascites
Petechiae
Dark urine
Correct Answer : A,B,C,D,E,F
A. Jaundice occurs due to the liver’s inability to process and excrete bilirubin, causing yellowing of the skin.
B. Clay-colored stools result from reduced bile flow into the intestines due to liver dysfunction.
C. Icterus (yellowing of the sclera) is a visible sign of bilirubin accumulation, common in late-stage liver disease.
D. Ascites, or fluid accumulation in the abdomen, occurs due to portal hypertension and low albumin production in cirrhosis.
E. Petechiae (small purple spots) result from impaired liver production of clotting factors, leading to bleeding tendencies.
F. Dark urine is caused by excess conjugated bilirubin being excreted by the kidneys due to the liver’s inability to process it properly.
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Related Questions
Correct Answer is D
Explanation
A. Droplet precautions are used for infections spread through respiratory droplets (e.g., influenza), which is not the mode of transmission for hepatitis C.
B. Contact precautions are necessary for organisms spread by direct touch (e.g., MRSA), but hepatitis C is not spread this way in routine care.
C. Airborne precautions are for diseases like tuberculosis or measles that spread via airborne particles, which is not the case for hepatitis C.
D. Standard precautions are appropriate for hepatitis C, as it is a bloodborne virus. Proper hand hygiene and the use of gloves when handling blood or body fluids are sufficient.
Correct Answer is D
Explanation
A. While elevating the head of the bed is helpful, 6 to 8 inches is the recommended range—not 18 inches, which is excessive and impractical.
B. Avoiding snacking is not a standard recommendation for GERD management; small, frequent meals are often encouraged.
C. High-fiber foods are generally beneficial and not contraindicated in GERD.
D. Avoiding food 2 to 3 hours before bedtime helps prevent nighttime reflux by reducing stomach contents during sleep, making this a key lifestyle modification for GERD.
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