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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

"I am at lower risk for developing cervical warts." This is an incorrect statement because the Gardasil vaccine does not protect against genital warts caused by HPV types other than types 6 and 11. The vaccine protects against HPV types 16 and 18, which cause most cases of cervical cancer.

B: This option is incomplete and does not provide any information for the nurse to determine if further teaching is needed.

C: This statement is correct and indicates that the client understands the purpose of the Gardasil vaccine.

D: This statement is incorrect because the Gardasil vaccine does not prevent HPV infection from occurring.

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

Explanation

Brudzinski sign is a clinical sign of meningitis, an inflammation of the membranes that cover the brain and spinal cord. It is characterized by reflexive flexion of the knees and hips following passive neck flexion13. To test for this sign, the examiner places one hand on the chest and the other behind the neck of the patient lying flat on the back, and then lifts the head forward. Brudzinski sign was first described by Polish pediatrician Józef Brudziński over 100 years ago. It may be absent, especially in young children.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young client has just completed the 6-month series of Gardasil vaccine. Which comment by the client would alert the nurse that further teaching is needed?

Correct Answer is A

Explanation

The nurse in the clinic is assessing a young child brought in by the parents with symptoms of meningitis. The nurse will assess for dropdown by asking the child to flex the chin to the neck.

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

Explanation

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