While performing a physical examination on a client with cirrhosis, which of the following interventions should the nurse report immediately to the physician?
Pode the client with non-prescription laxatives.
Measure abdominal girth according to a set routine.
Ask the client about food intake.
Check for signs of hepatic encephalopathy.
The Correct Answer is A
Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.
Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.
Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.
Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.
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Related Questions
Correct Answer is C
Explanation
Ischemic. Imaging studies indicate an occlusion partially obstructing the right carotid artery, which may result in reduced blood flow to the brain, leading to ischemia. Ischemic stroke is caused by a blocked or narrowed artery that supplies blood to the brain.
Option A: Right-sided and Option B: Left-sided are not correct answers as they refer to the location of the stroke, which cannot be determined by the information provided in the question.
Option D: Hemorrhagic is not a correct answer as it is caused by bleeding in the brain, not a blocked or narrowed artery.
Correct Answer is D
Explanation
Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.
Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.
Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.
Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.
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