ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 47 Questions
Question 1 of 5
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. How does the nurse document this finding?
Correct Answer: C
Rationale: Caput medus is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.
Question 2 of 5
A nurse is preparing a presentation for a local community group about hepatitis. Which information would the nurse include?
Correct Answer: C
Rationale: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route, hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
Question 3 of 5
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which intervention should the nurse consider?
Correct Answer: B
Rationale: If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
Question 4 of 5
The nurse is caring for a client who has undergone surgery for a liver disorder and has started shivering. Which intervention would be appropriate?
Correct Answer: B
Rationale: The nurse should cover the client with a light blanket to prevent shivering. This is because the client who has undergone surgery for liver disorder also faces the risk of hyperthermia related to infection, rejection, or both. Providing the client with warm fluids will not control shivering. The client is covered with a hypothermia blanket if the temperature rises to 105?°F. The room temperature need not be below 70?°F.
Question 5 of 5
The nurse is assessing a client with suspected cholelithiasis. What can the nurse expect to observe?
Correct Answer: D
Rationale: When a client is being assessed for cholelithiasis, the urine appears dark brown, whereas the stools may be light-colored. Bowel sounds are present because cholelithiasis does not cause lack of bowel motility. The stool does not contain blood or mucus.