While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?
Decreased bowel sounds.
Increased respiratory rate.
Increased abdominal girth.
Decreased level of consciousness.
The Correct Answer is C
Choice A reason: Decreased bowel sounds may be associated with cirrhosis due to altered digestion but do not directly correlate with weight gain.
Choice B reason: An increased respiratory rate can be a sign of many conditions, including fluid overload, but it is not a specific indicator of weight gain due to fluid accumulation.
Choice C reason: Increased abdominal girth is a common sign of ascites, which is fluid accumulation in the abdomen often seen in cirrhosis, correlating with the reported weight gain.
Choice D reason: Decreased level of consciousness may indicate hepatic encephalopathy in cirrhosis patients but does not directly correlate with the weight gain described.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Asking for specifics about the night nurse's behavior could reinforce the client's splitting behavior, which is not therapeutic.
Choice B reason: Promising to talk to the night nurse may validate the client's negative perception without understanding the full context.
Choice C reason: Focusing on the client's progress and upcoming discharge avoids engaging in a discussion that could reinforce dichotomous thinking.This response is non-confrontational and avoids engaging in the client’s dichotomous thinking. It focuses on the positive aspect of the client’s situation, which is their improvement and discharge from the hospital. It’s important for healthcare professionals to maintain professional boundaries and not reinforce potentially harmful behavior patterns.
Choice D reason: Seeking details about the client's preference for certain staff can encourage splitting behavior and is not beneficial.
Correct Answer is ["A","E"]
Explanation
Choice A reason: Allergic rhinitis is a common condition that responds well to antihistamines, which can alleviate symptoms such as sneezing, runny nose, and itching.
Choice B reason: Otitis media is an inflammation of the middle ear and is not typically treated with antihistamines.
Choice C reason: Myocarditis is an inflammation of the heart muscle and is not treated with antihistamines.
Choice D reason: Bronchitis involves inflammation of the bronchial tubes and is not primarily treated with antihistamines.
Choice E reason: Contact dermatitis, which is an allergic skin reaction, can be treated with antihistamines to relieve itching and rash.
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