A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

Decreased bowel sounds.

Increased respiratory rate.

Increased abdominal girth.

Decreased level of consciousness.

Answer and Explanation

The Correct Answer is C

Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.

Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.

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Correct Answer is D

Explanation

Choice A reason: Asking if there is a particular reason why the parent thinks it's their fault may inadvertently validate feelings of self-blame, which is not helpful in this sensitive situation.

Choice B reason: While reassuring the parent they did nothing wrong is true, it may not address the emotional support the parent needs at this moment.

Choice C reason: Promising a full recovery with surgery may be misleading and give false hope, as outcomes can vary and myelomeningocele often results in some degree of impairment.

Choice D reason: Acknowledging the parent's feelings and the difficulty of the situation provides emotional support and validation without assigning blame or making promises about the outcome.

A. Document concerns and report them to the charge nurse. B. Talk to the physician as a group in a non-confrontational manner. C. Submit a written report to the Director of Nursing. D. Contact the hospital's Chief of Medical Services. E. File a formal complaint with the state medical board.

Correct Answer is A,B,C,D,E

Explanation

Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit.

Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation.

Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action.

Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure.

Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.

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A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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