A client with liver cirrhosis and ascites is experiencing abdominal pain and discomfort. The nurse should recognize that this pain is primarily due to:
Increased liver enzyme levels.
Gallstone formation in the gallbladder.
Stretching of the abdominal wall from fluid accumulation.
Inflammation of the pancreas.
The Correct Answer is C
Choice A reason:
Increased liver enzyme levels are not directly related to the abdominal pain and discomfort experienced by the client with ascites. Elevated liver enzymes indicate liver damage, but they do not cause abdominal pain.
Choice B reason:
Gallstone formation in the gallbladder is not directly related to the abdominal pain and discomfort experienced by the client with ascites.
Choice C reason:
This statement is correct. The abdominal pain and discomfort experienced by the client with ascites are primarily due to the stretching of the abdominal wall from the accumulation of fluid in the abdominal cavity.
Choice D reason:
Inflammation of the pancreas (pancreatitis) is not directly related to the abdominal pain and discomfort experienced by the client with ascites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This statement is correct. Measuring abdominal girth and documenting findings are essential to monitor changes in fluid accumulation and assess the effectiveness of interventions.
Choice B reason:
Elevating the client's legs may help with edema in the lower extremities but will not directly address the fluid accumulation in the abdominal cavity.
Choice C reason:
Administering diuretics may be part of the management plan for ascites, but it may not be the initial intervention to address the client's current condition.
Choice D reason:
Applying an abdominal binder may be beneficial in certain cases, but it will not directly address the underlying cause of ascites or reduce fluid accumulation in the abdomen.
Correct Answer is D
Explanation
Choice A reason:
Mild ankle edema is not uncommon in clients with fluid retention, such as ascites. While it requires monitoring, it does not indicate an immediate need for intervention.
Choice B reason:
Moderate abdominal distention is a common finding in clients with ascites and should be monitored, but it does not require immediate intervention.
Choice C reason:
Complaints of thirst and dry mouth may indicate dehydration, which should be addressed, but it does not require immediate intervention as other options.
Choice D reason:
This statement is correct. Respiratory distress and cyanosis are concerning findings in a client with ascites, as they may indicate severe pulmonary edema or other respiratory complications that require immediate intervention and medical attention.
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