A nurse is caring for a client who has cirrhosis of the liver and is receiving spironolactone. Which of the following findings indicates that the client responding to the treatment?

Increased appetite

Decreased jaundice

Decreased ascites

Increased energy

Answer and Explanation

The Correct Answer is C

A.   Increased appetite is not a direct indicator of spironolactone effectiveness.
B.   Decreased jaundice may occur with overall improvement in liver function but is not a direct indicator of spironolactone effectiveness.
C.   Decreased ascites indicates that spironolactone is effectively reducing fluid retention, which is a primary goal in managing cirrhosis.
D.   Increased energy can be a positive sign but is not a direct measure of the effectiveness of spironolactone.

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Correct Answer is A

Explanation

A. This response respects the client's autonomy and fear while offering to discuss alternative treatments, which may increase the client's willingness to receive care.
B. This statement is authoritative and does not respect the client's concerns or autonomy.
C. While it may be true, it does not address the client's fear effectively or offer alternatives.
D. This statement is coercive and does not provide the client with supportive information or options.

A. Administer epinephrine IM. B. Elevate the client's legs and feet. C. Give diphenhydramine IM. D. Replace the infusion with 0.9% sodium chloride.

Correct Answer is A

Explanation

A. Administering epinephrine IM is the priority action to counteract the severe allergic reaction and prevent further deterioration.
B. Elevating the legs and feet is important but secondary to administering epinephrine.
C. While diphenhydramine can help, epinephrine is the first-line treatment for anaphylaxis.
D. Replacing the infusion with 0.9% sodium chloride is important to maintain IV access but should be done after administering epinephrine.

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A nurse is caring for a client who has cirrhosis of the liver and is receiving spironolactone. Which of the following findings indicates that the client responding to the treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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