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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Eustachian tube. The Eustachian tube is a narrow tube that connects the middle ear to the back of the nose and equalizes air pressure in the middle ear.
B. The malleus is a bone in the middle ear that transmits sound vibrations.
C. The pinna is the visible part of the ear that collects and directs sound waves.
D. The meatus is a passage or opening leading to the ear or nose.
Correct Answer is B
Explanation
In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.
Choice A is incorrect because it describes the Weber test, not the Rinne test.
Choice C is incorrect because it is not a standard hearing test.
Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.
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