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The nurse is planning care for the client diagnosed with liver cancer experiencing ascites. The nurse would include which of the following?

A.

Limiting visits by family members and friends

B.

Assessment of amylase and lipase

C.

Abdominal assessment including abdominal girth

D.

Continuous cardiac monitoring

Answer and Explanation

The Correct Answer is C

A. Limiting visits by family members and friends is not necessary for managing ascites and could hinder the client's emotional support.  
B. While amylase and lipase are important in assessing pancreatic function, they are not directly relevant to ascites management or liver cancer.  
C. An abdominal assessment including abdominal girth is crucial for monitoring ascites, as changes in girth can indicate fluid accumulation or changes in the client's condition.  
D. Continuous cardiac monitoring is not typically indicated for clients with liver cancer experiencing ascites unless there are specific cardiac concerns.  
 


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Related Questions

Correct Answer is B

Explanation

A. Magnesium at 2.0 mEq/L is within the normal range (1.6-2.2 mg/dL) and does not require immediate intervention.
B. A serum sodium level of 126 mEq/L indicates hyponatremia, which can lead to neurological complications, particularly in patients with brain cancer. Immediate reporting is necessary to manage potential risks such as seizures or altered mental status.
C. A potassium level of 3.5 mEq/L is on the lower limit of normal (3.5-5.3 mEq/L) but is still considered acceptable and does not require urgent action.
D. Calcium at 10 mg/L is an incorrect unit for this context, as total serum calcium is typically measured in mg/dL, and 10 mg/dL falls within the normal range (8.2-10.2 mg/dL).

Correct Answer is C

Explanation

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

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