. A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?
Monitoring of results of liver function testing
Assessment for signs and symptoms of jaundice
Measurement of abdominal girth and body weight
Assessment for variceal bleeding
The Correct Answer is C
A. Monitoring of results of liver function testing: While important, monitoring liver function tests is a routine assessment rather than a prioritized one compared to assessing for complications like ascites.
B. Assessment for signs and symptoms of jaundice: Jaundice is a common finding in cirrhosis but does not necessarily indicate an acute complication.
C. Measurement of abdominal girth and body weight: In advanced cirrhosis, monitoring for ascites and fluid retention is critical as these indicate worsening disease and potential complications.
D. Assessment for variceal bleeding: Incorrect. While important, the priority in routine assessment is monitoring for ascites and fluid overload, which can be managed more readily.
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Related Questions
Correct Answer is D
Explanation
A. "Your liver cannot manufacture bile": The liver can still manufacture bile, but the problem lies in bile flow, not production.
B. "Your pancreas is no longer able to manufacture insulin": This statement refers to diabetes, not cholelithiasis.
C. "Your gall bladder is not contracting properly": While gallbladder dysfunction can cause pain, jaundice specifically occurs due to bile flow obstruction, not just poor contraction.
D. "A gallstone can prevent bile from flowing into the intestines": Gallstones can obstruct the bile ducts, leading to a buildup of bilirubin in the blood, which manifests as jaundice.
Correct Answer is C
Explanation
A. Ask a family member to interpret what the client is trying to communicate: While family members can sometimes help, the nurse should directly facilitate communication with the client using appropriate tools.
B. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk: Weaning off a ventilator should only be done based on medical stability, not solely for communication purposes.
C. Ask the client to write, use a picture board, or spell words with an alphabet board: These tools can help non-verbal clients on mechanical ventilation express themselves and reduce frustration.
D. Assure the client that everything will be all right and that he shouldn't become upset: This response is dismissive and does not address the client's need to communicate.
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