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 A
Explanation
Choice A reason: The immediate activation of the lockdown procedure is critical in the event of a suspected infant abduction, as it helps to secure the facility and prevent the unauthorized removal of the infant.
Choice B reason: Matching ID bands is a standard procedure but not the first action to take in a potential abduction scenario.
Choice C reason: Asking the mother about expected visitors is part of the investigation but does not take precedence over securing the facility.
Choice D reason: Determining if the newborn is in the nursery is important but should follow the immediate security measures.
Correct Answer is B
Explanation
Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.
Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.
Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.
Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.
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