When performing a physical examination on a client with cirrhosis, a nurse notices that the abdomen is enlarged. Which of the following interventions should the nurse consider?
Report the condition to the physician immediately.
Provide the client with nonprescription laxatives.
Measure abdominal girth according to a set routine.
Ask the client about food intake.
The Correct Answer is C
Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.
Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.
Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.
Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Level of consciousness is improving. The effectiveness of mannitol treatment for a client with increased intracranial pressure can be assessed through the improvement of the level of consciousness. Mannitol is an osmotic diuretic that reduces cerebral edema and intracranial pressure. It works by increasing the osmotic pressure in the bloodstream, which draws fluid out of the brain and into the bloodstream. The reduction of intracranial pressure helps improve cerebral perfusion and blood flow. Therefore, improving the client's level of consciousness is the most important assessment finding to determine the effectiveness of mannitol treatment.
B is not the correct answer because a rise in blood pressure is not an indicator of the effectiveness of mannitol treatment.
C is not the correct answer because increased urine output is a side effect of mannitol treatment and does not necessarily indicate effectiveness.
D is not the correct answer because hyperpyrexia is not a symptom that is treated with mannitol.
Correct Answer is D
Explanation
Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.
Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.
Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.
Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today