A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

Position the client flat in bed.

Weigh the client weekly.

Medicate the client with acetaminophen for discomfort.

Measure the client’s abdominal girth every 8 hours.

Answer and Explanation

The Correct Answer is D

a. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.

b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.

c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.

d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.

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Correct Answer is C

Explanation

a. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.

b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.

c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.

d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.

A. Weight gain B. Constipation C. Frequent mood changes D. Sensitivity to cold

Correct Answer is C

Explanation

a. Weight gain: Hyperthyroidism is more commonly associated with weight loss due to increased metabolism.

b. Constipation: Hyperthyroidism is more likely to cause diarrhea or increased bowel movements.

c. Frequent mood changes: Hyperthyroidism can lead to mood swings, irritability, and anxiety.

d. Sensitivity to cold: Sensitivity to cold is more commonly associated with hypothyroidism, not hyperthyroidism.

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A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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