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
drug allergy. A skin rash is a common symptom of an allergic reaction to a medication, and a drug allergy can occur at any time during drug therapy. A drug allergy may be due to an immune response, causing the immune system to overreact to a medication that it identifies as harmful to the body. The symptoms of a drug allergy may include a rash, hives, itching, or difficulty breathing. It is important for the nurse to determine which medication the client is taking and if the client has a history of allergies.
Heat stroke (B) occurs when the body is exposed to high temperatures, leading to symptoms such as high body temperature, confusion, and loss of consciousness. Hormone changes (C) can cause various changes in the body but do not usually cause skin rashes. A suntan (D) is a reaction of the skin to ultraviolet light and is not a cause of a skin rash.
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.
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