A client with liver cirrhosis is experiencing fluid retention and abdominal distension due to ascites. Which nursing intervention is essential to manage this complication?
Restricting fluid intake to reduce edema.
Encouraging the client to consume a high-sodium diet.
Assisting with paracentesis to drain the ascitic fluid.
Administering diuretics to promote urine output.
The Correct Answer is C
A) Restricting fluid intake is not appropriate for managing ascites in clients with liver cirrhosis. Ascites occurs due to fluid accumulation in the peritoneal cavity and is not primarily influenced by oral fluid intake.
B) Encouraging a high-sodium diet is contraindicated in clients with ascites. High sodium intake can exacerbate fluid retention and worsen ascites. Instead, clients with ascites should be on a low-sodium diet to reduce fluid accumulation.
C) In a client with liver cirrhosis experiencing fluid retention and abdominal distension due to ascites, paracentesis is an essential intervention to drain the accumulated ascitic fluid from the abdominal cavity. Paracentesis helps to relieve discomfort, improve respiratory function, and reduce intra-abdominal pressure.
D) Diuretics are used in the management of ascites to promote urine output and reduce fluid retention. However, paracentesis is a more immediate intervention for relieving discomfort and removing a large volume of ascitic fluid.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Iron supplements are not a priority intervention for a client with hepatic encephalopathy. In fact, administering iron supplements without proper indication can be harmful, as excessive iron can worsen liver damage in cirrhosis.
B) While monitoring fluid intake and output is important in managing various aspects of liver cirrhosis, it is not the essential intervention for hepatic encephalopathy. The priority in hepatic encephalopathy is to ensure seizure precautions and address the client's altered mental status.
C) Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis that can lead to altered mental status, confusion, and potential seizures. Implementing seizure precautions is essential in the care of this client to ensure their safety and prevent injury during any potential seizure activity. Seizure precautions may include padding the side rails of the bed, ensuring a clear and clutter-free environment, and providing close supervision to the client. In severe cases, the healthcare provider may prescribe antiepileptic medications to manage and prevent seizures.
D) Encouraging a high-protein diet is not appropriate for a client with hepatic encephalopathy. High-protein diets can exacerbate hepatic encephalopathy by increasing ammonia production in the intestines. Instead, the client should be prescribed a controlled-protein diet and, in some cases, given lactulose to help reduce ammonia levels.
Correct Answer is D
Explanation
A) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not typically associated with difficulty sleeping or shortness of breath.
B) Portal hypertension, a common complication of liver cirrhosis, can lead to the development of ascites and esophageal varices, among other manifestations. It is not the likely cause of the client's difficulty sleeping and shortness of breath.
C) Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease and is not associated with difficulty sleeping or shortness of breath.
D) Hepatopulmonary syndrome is a complication of liver cirrhosis characterized by the development of pulmonary vascular dilation and arteriovenous shunting. This results in impaired oxygenation of blood, leading to difficulty breathing (dyspnea), especially while lying down (orthopnea). Clients with hepatopulmonary syndrome often experience frequent awakenings due to shortness of breath during sleep.
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