LIVER (select all that apply)

The nurse assesses a patient who is diagnosed with decompensated cirrhosis. Which of the following are clinical indicators consistent with that diagnosis? Select all that apply. A. A firm, enlarged liver B. Ascites C. Jaundice D. Clubbing of the fingers E. Vascular spiders F. Splenomegaly

B,C,D, R: Refer to Box 25-9 in the text.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply. A. Cyanosis of the lips B. Ecchymoses C. Jaundice D. Aphthous stomatitis E. Petechiae

B,C,E R:The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply. A. change in mental status B. signs of GI bleeding C. anorexia and dyspepsia D. diarrhea or constipation

A,B R:The nurse reports any change in mental status or signs of GI bleeding immediately because they indicate secondary complications.

A client has received a diagnosis of portal hypertension. What does portal hypertension treatment aim to reduce? Select all that apply. A. venous pressure B. fluid output C. fluid accumulation D. blood coagulation

A,C R:Methods of treating portal hypertension aim to reduce venous pressure and fluid accumulation.