. 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pulmonary crackles/rales: Left-sided heart failure leads to a buildup of fluid in the lungs, causing pulmonary congestion and crackles/rales on auscultation.
B. Weight gain: This is more commonly associated with right-sided heart failure due to fluid retention, though it can be seen in both types of heart failure.
C. Hepatomegaly: Hepatomegaly is typically associated with right-sided heart failure due to congestion in the systemic circulation.
D. Jugular vein distention: JVD is a sign of right-sided heart failure, as it indicates increased central venous pressure.
Correct Answer is C
Explanation
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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