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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.
b. Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initial
postoperative period.
c. Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk of
complications such as atelectasis.
d. Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to prevent
complications such as atelectasis.
Correct Answer is A
Explanation
a. Postictal phase: The postictal phase refers to the period following a seizure during which the individual may be drowsy, confused, or sleepy. This phase can last varying amounts of time.
b. Presence of absence seizures: Absence seizures are characterized by brief episodes of staring and altered consciousness but do not typically have a postictal phase with prolonged sleepiness.
c. Aura phase: The aura phase occurs before a seizure and involves sensory or perceptual changes that serve as a warning sign. It does not describe the postictal state.
d. Presence of automatisms: Automatisms are repetitive, non-purposeful movements that can occur during certain types of seizures but do not describe the postictal state of sleepiness.
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