A nurse is collecting data from a client who has cirrhosis of the liver. Which of the following findings should the nurse identify as the priority?
Explanation & Rationale
A. Clay-colored stools: Clay-colored stools indicate a lack of bile flow due to liver dysfunction, which is expected in cirrhosis. While concerning, it is not the most urgent finding compared to signs indicating acute neurological compromise. B. Confusion: Confusion suggests hepatic encephalopathy, a serious complication of cirrhosis resulting from the buildup of toxins like ammonia in the bloodstream. It indicates potential cerebral impairment and requires immediate provider notification and intervention to prevent progression to coma. C. Spider angiomas: Spider angiomas are small, dilated blood vessels visible on the skin, commonly seen in cirrhosis due to hormonal changes and altered vascular dynamics. They are a chronic sign of liver disease and do not represent an immediate threat. D. Jaundice: Jaundice results from elevated bilirubin levels due to impaired liver function. While jaundice signals worsening liver disease, it develops gradually and is less immediately life-threatening than the onset of neurological symptoms like confusion.