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 B
Explanation
Choice A reason: Eating high-protein foods to achieve ideal body weight is generally a healthy practice, but it is not directly related to the management of the client's current condition involving pain in the toe.
Choice B reason: Patients with gouty arthritis should avoid acetylsalicylic acid (aspirin) as it can lead to an increase in uric acid levels, potentially exacerbating gout attacks. Instead, medications that do not affect uric acid levels should be used for pain relief.
Choice C reason: Wrapping joints with an elastic bandage can provide support and reduce swelling, but it is not the primary intervention for sudden pain in the toe following an appendectomy, especially when the patient has a history of gouty arthritis.
Choice D reason: Supporting joints in an extended position while resting can provide comfort and may prevent stiffness, but it does not address the acute management of gouty arthritis or diabetic complications that could be causing toe pain.
Correct Answer is B
Explanation
Choice A reason:Deferring to the provider does not address the confidentiality issue; it suggests the nurse is unwilling rather than clarifying the legal obligation to protect an adult client’s health information.
Choice B reason: By stating that only the client can authorize release of their own medical data, the nurse accurately reflects HIPAA and patient‑privacy regulations for an adult. This response both informs the parent and upholds the client’s right to confidentiality.
Choice C reason: This response is inappropriate and unprofessional. It fails to acknowledge the parent's concern and does not provide a constructive way to address the situation.
Choice D reason: While this response may seem helpful, it is not the nurse's role to promise lab results, especially when there are privacy laws that restrict the sharing of medical information with anyone other than the patient unless consent has been given.
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