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Which assessment findings are consistent with cirrhosis? Select all that apply.

Jaundice

Spider angiomas

Lethargic

Apical pulse regular with S1, S2

Abdomen moderately distended

Dark amber urine

Peripheral pulses are palpable

3+ pitting edema

Answer and Explanation

Correct Answer : A,B,E,F,H

Choice A reason: Jaundice is a common finding in cirrhosis due to impaired liver function, which leads to the accumulation of bilirubin in the blood. This causes the skin and the whites of the eyes to turn yellow.
Choice B reason: Spider angiomas are dilated blood vessels that appear on the skin and are often seen in patients with cirrhosis. They are caused by increased estrogen levels due to impaired liver function.
Choice C reason: Lethargy is a symptom of cirrhosis as the liver's ability to detoxify the blood is compromised, leading to fatigue and weakness.
Choice D reason: An apical pulse regular with S1, S2 is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice E reason: Abdomen moderately distended is consistent with cirrhosis due to the accumulation of fluid in the abdominal cavity (ascites), which is a common complication of advanced liver disease.
Choice F reason: Dark amber urine is a sign of cirrhosis as the liver's ability to process bilirubin is impaired, leading to the excretion of conjugated bilirubin in the urine, which gives it a dark color.
Choice G reason: Peripheral pulses are palpable is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice H reason: 3+ pitting edema is consistent with cirrhosis due to the retention of sodium and water, leading to swelling in the lower extremities.

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Correct Answer is D

Explanation

Choice A reason: Cardiac dysrhythmias are not the primary concern in a patient with acute cholecystitis. Although severe pain can lead to stress on the cardiovascular system, it is not the main priority in this scenario. Hypotension can be a concern due to dehydration from vomiting, but pain management is addressed more comprehensively under fluid and electrolyte balance and infection control.
Choice B reason: Wound dehiscence is not relevant in this case as the patient has not undergone surgery yet. Fluid and electrolyte imbalance and hypotension are important considerations due to the patient’s nausea and vomiting, but wound dehiscence does not apply to her current state of care.
Choice C reason: The inadequate diet is a consideration due to the patient's inability to eat or drink, and hypotension is a risk due to dehydration. However, wound dehiscence is still not relevant since the patient has not had a surgical procedure yet. Preventing an inadequate diet is part of the broader management but not the immediate priority.
Choice D reason: Infection, fluid and electrolyte imbalance, and pain are the most relevant concerns for a patient with acute cholecystitis. The nasogastric tube and IV fluids are vital for managing her dehydration and electrolyte imbalances. The patient's high pain level (9/10) indicates severe discomfort that must be managed effectively. Additionally, with the insertion of a nasogastric tube and the risk of cholecystitis-related complications, preventing infection is a key priority.

A. "I need to shop for foods low in sodium and avoid adding salt to food." B. "I need to limit my fluid intake." C. "I should eat foods high in potassium because diuretics cause potassium loss." D. "I should weigh myself daily and report sudden weight loss or gain."

Correct Answer is ["B","C"]

Explanation

Choice A reason: "I need to shop for foods low in sodium and avoid adding salt to food." This statement is correct and indicates appropriate understanding. Patients with SIADH need to manage their sodium intake carefully to avoid exacerbating hyponatremia.
Choice B reason: "I need to limit my fluid intake." This statement indicates a misunderstanding. Patients with SIADH should actually increase their fluid intake to help dilute the excess antidiuretic hormone and reduce hyponatremia. Limiting fluid intake can worsen the condition.
Choice C reason: "I should eat foods high in potassium because diuretics cause potassium loss." This statement is incorrect in the context of SIADH. While potassium intake is important for patients on diuretics, it is not directly related to SIADH management. The focus should be on managing fluid and sodium levels.
Choice D reason: "I should weigh myself daily and report sudden weight loss or gain." This statement is correct and indicates appropriate understanding. Regular weight monitoring is important for patients with SIADH to detect fluid imbalances early.

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Which assessment findings are consistent with cirrhosis? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Based on the patient's current condition, the nurse recognizes that the patient's priority needs will be to prevent:

Correct Answer is D

Explanation

Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

Correct Answer is ["B","C"]

Explanation

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