The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Provide only distilled water.

Document abdominal girth.

Offer a high protein diet.

Use a cushion when sitting.

Answer and Explanation

The Correct Answer is B

A.   Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B.   Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D.   Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The neck is the correct location for auscultating a carotid bruit. A carotid bruit is an abnormal sound heard over the carotid artery in the neck, typically indicative of turbulent blood flow due to a narrowing or blockage in the artery.

B. Auscultating the femoral region would not yield information about carotid bruits. The femoral region pertains to the upper thigh area and is not anatomically related to the carotid artery.

C. The cubital fossa is the inner elbow region and is not associated with auscultation for carotid bruits. It is typically used for auscultation of blood pressure using the brachial artery.

D. The navel (belly button) is not a relevant location for auscultation for carotid bruits. It is far from the carotid arteries and would not provide any meaningful information about carotid artery sounds.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

A. Functional Improvement: This is crucial to assess because it indicates the effectiveness of the interventions implemented, such as physical and occupational therapy, and the overall progress of the client in regaining independence in activities of daily living. Tracking functional improvements helps determine if the client's physical abilities, mobility, and self- care skills are improving over time, which is essential for their overall well-being and quality of life.

B. Psychological Assessment: This aspect is important to evaluate because it helps gauge the client's mental and emotional well-being. Elderly individuals who are subjected to neglect or mistreatment, as in this case, may experience psychological distress, such as depression, anxiety, or feelings of helplessness. Monitoring the client's psychological status allows the nurse to identify any signs of emotional distress or trauma resulting from their situation, enabling appropriate interventions to support their mental health and emotional stability.

Additionally, assessing the caregiver's psychological well-being is also crucial as they may experience stress, burnout, or emotional strain from the caregiving responsibilities, which can impact the quality of care provided to the client.

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The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

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