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A nurse is caring for a client in the emergency room.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale:

  • Potential Condition: The client presents with jaundice, ascites, abdominal distention, confusion, and abnormal liver function tests (elevated AST, ALT, and bilirubin, with low albumin), consistent with cirrhosis and fluid volume excess.
  • Actions to Take:
    • Administer diuretics (such as spironolactone or furosemide) to reduce fluid retention and help manage ascites.
    • Monitor fluid intake and output to evaluate fluid balance and effectiveness of diuretic therapy.
  • Parameters to Monitor:
    • Blood pressure is important because hypotension is present and can worsen with fluid shifts and diuretic therapy.
    • Abdominal girth is monitored to track the progression or reduction of ascites.


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Related Questions

Correct Answer is ["A","C","D"]

Explanation

Rationale:

  • Diarrhea is one of the most frequent gastrointestinal side effects of antibiotics due to alteration of normal intestinal flora and increased motility.
  • Nausea is a common adverse reaction as antibiotics can irritate the stomach lining or affect gut motility.
  • Abdominal pain may occur secondary to irritation of the gastrointestinal tract or as part of antibiotic-associated colitis.
  • Clostridium difficile infections are a serious complication, not a routine side effect, requiring immediate evaluation and intervention.
  • Vomiting may occur but is less common compared to nausea and diarrhea.
  • Loss of healthy bacteria is the underlying mechanism of many side effects, but it is not typically described to clients as a direct side effect.

Correct Answer is ["D","E","F"]

Explanation

Rationale:

  • Improved breathing indicates that the removal of ascitic fluid has relieved diaphragmatic pressure, allowing better lung expansion.
  • Decreased abdominal pressure demonstrates that fluid removal has reduced intra-abdominal tension, improving mobility and comfort.
  • Relief of abdominal discomfort is a primary goal of paracentesis, as it enhances quality of life and reduces pain caused by fluid accumulation.
  • Stable vital signs and absence of respiratory distress are important for monitoring safety but are not direct measures of the procedure’s effectiveness.
  • Reduced ascitic fluid volume is the mechanism of action of paracentesis, while the client’s symptomatic relief is the best indicator of clinical success.

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