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: Avoiding sunscreen is not recommended as it increases the risk of skin cancer; vitamin D can be obtained safely through diet and supplements.
Choice B reason: While it is true that vitamin D and calcium are balanced with phosphorus, this statement does not directly encourage compliance with supplementation.
Choice C reason: Although calcium uses vitamin D produced by sunlight exposure, relying solely on sunshine is not sufficient, especially for individuals at risk of osteoporosis.
Choice D reason: Emphasizing that vitamin D enhances calcium absorption into the bone provides a clear rationale for the client to comply with the supplementation regimen.
Correct Answer is C
Explanation
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
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