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 C

Explanation

Choice A reason: Encouraging the client to walk thirty minutes every day is a good practice but does not directly relate to the immediate outcome of managing chest pain.

Choice B reason: Monitoring blood glucose and blood pressure is part of ongoing management but is not a specific outcome related to exertional chest pain.

Choice C reason: Maintaining a daily blood pressure of less than 140/80 mm Hg is a specific and measurable outcome that can help manage symptoms of cardiovascular disease and prevent complications.

Choice D reason: A blood pressure reading of less than 160/90 mm Hg is less stringent than current guidelines suggest for optimal control in cardiovascular disease.

A. Administer an IV analgesic. B. Assess the IV site for patency. C. Provide a pillow for splinting. D. Place in a high-Fowler's position.

Correct Answer is A

Explanation

Choice A reason: The priority is to manage the client's severe pain, which can be achieved through the administration of an IV analgesic. Effective pain management is crucial for postoperative recovery and can prevent complications related to increased pain, such as elevated heart rate and blood pressure.

Choice B reason: While assessing the IV site for patency is important, it is not the most critical intervention when a client is experiencing severe pain.

Choice C reason: Providing a pillow for splinting can help with pain management during movement or coughing but does not directly address the immediate need for pain relief.

Choice D reason: Placing the client in a high-Fowler's position may aid in comfort and breathing but is not the most important intervention for severe pain management.

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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

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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