A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

A. Decreased reflexes can indicate electrolyte imbalance, particularly hypokalemia, which is a common adverse effect of loop diuretics. Low potassium levels can affect neuromuscular function and should be reported and addressed promptly.

B. A weight gain of 1.4 kg (3 lb) suggests fluid retention and worsening heart failure, not an adverse effect of the diuretic. Loop diuretics are expected to promote weight loss through fluid removal.

C. Increased urinary output is an expected therapeutic effect of a loop diuretic and indicates the medication is working as intended.

D. Jugular vein distention reflects fluid volume overload associated with heart failure rather than an adverse medication effect.

A.

A. Monitor for abdominal ascites - Ascites is a common complication of cirrhosis due to portal hypertension and decreased albumin production. Monitoring for abdominal distention and fluid

accumulation is essential for assessing the progression of cirrhosis and implementing appropriate interventions.

B. Implement a low-carbohydrate diet - While dietary modifications may be necessary for clients with cirrhosis, such as reducing sodium intake, implementing a low-carbohydrate diet is not typically a primary intervention for cirrhosis.

C. Review serum amylase levels - Serum amylase levels are typically assessed to diagnose pancreatitis, which is not directly related to cirrhosis unless complications such as alcoholic pancreatitis are present.

D. Place warm compresses on areas of pruritus - Pruritus (itching) is a common symptom of liver disease, including cirrhosis, due to bile salt accumulation. While warm compresses may provide

temporary relief, they do not address the underlying cause of pruritus in cirrhosis.