A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?
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 indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.
Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.
Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.
Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While developing new screening protocols is a positive step, it does not directly measure the effectiveness of the prevention program in terms of client outcomes or behavior change.
Choice B reason: Early diagnosis of at-risk clients is important, but it is a secondary measure of effectiveness that follows education and behavior change, which are primary prevention strategies.
Choice C reason: Prompt rehabilitation for clients with disease complications is a form of tertiary prevention and does not reflect the effectiveness of the primary prevention program.
Choice D reason: Improvement in client knowledge about specific risk factors as evidenced by test scores is a direct measure of the effectiveness of an educational prevention program. It indicates that clients have understood and potentially internalized the information necessary to prevent sexually transmitted diseases, which is the goal of primary prevention.
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.
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