A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

Monitor for abdominal ascites.

Implement a low-carbohydrate diet.

Review serum amylase levels.

Place warm compresses on areas of pruritus

Answer and Explanation

The Correct Answer is A

A. Monitor for abdominal ascites: Clients with cirrhosis are at risk for fluid accumulation in the peritoneal cavity due to portal hypertension and hypoalbuminemia. Monitoring abdominal girth, weight, and signs of fluid retention is essential for early detection and timely intervention to prevent complications such as respiratory compromise or infection.

B. Implement a low-carbohydrate diet: Cirrhosis does not typically require a low-carbohydrate diet; instead, clients often need adequate calories and protein to prevent malnutrition. Restricting carbohydrates unnecessarily can worsen energy deficits and muscle wasting.

C. Review serum amylase levels: Serum amylase is primarily used to assess pancreatic function, not liver function. Liver disease monitoring focuses on liver enzymes (AST, ALT), bilirubin, and coagulation studies rather than amylase levels.

D. Place warm compresses on areas of pruritus: Pruritus in cirrhosis is better managed with cool baths, moisturizing creams, or medications like cholestyramine. Warm compresses can exacerbate itching by increasing skin blood flow and should generally be avoided.

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Correct Answer is A

Explanation

A. Banana slices: Soft, ripe bananas are easy for toddlers to chew and swallow, making them a safe option that minimizes the risk of choking and aspiration. Cutting the fruit into small, manageable pieces further reduces the risk and aligns with recommended feeding practices for young children.

B. Popcorn: Popcorn is a high-risk food for toddlers due to its small, hard, and irregular pieces that can easily lodge in the airway. It should be avoided in young children to prevent choking and aspiration hazards.

C. Hot dogs: Whole or large pieces of hot dogs are a major choking risk for toddlers because they are firm, slippery, and can block the airway. If served, they should be cut into very small, lengthwise pieces, but they are generally not recommended for very young children.

D. Seeded grapes: Grapes with seeds are hard and round, posing a significant aspiration risk for toddlers. Seeds increase the likelihood of airway obstruction, making this food unsafe for young children without proper modification.

A. Shakiness B. Confusion C. Thirst D. Diaphoresis

Correct Answer is C

Explanation

A. Shakiness: Shakiness is typically a manifestation of hypoglycemia, resulting from activation of the sympathetic nervous system. It occurs when blood glucose drops below normal levels, not with hyperglycemia, so it is not associated with a glucose level of 265 mg/dL.

B. Confusion: Confusion can occur with both severe hyperglycemia and hypoglycemia, but it is more pronounced in extreme elevations of blood glucose or in hyperosmolar hyperglycemic states. A level of 265 mg/dL may not yet cause marked cognitive changes in all clients.

C. Thirst: Hyperglycemia causes osmotic diuresis, leading to fluid loss and dehydration, which triggers excessive thirst (polydipsia). This is a common and early clinical manifestation associated with elevated blood glucose levels such as 265 mg/dL.

D. Diaphoresis: Diaphoresis, or excessive sweating, is primarily a symptom of hypoglycemia caused by adrenergic stimulation. It is not a typical manifestation of hyperglycemia and is unlikely to occur with a blood glucose of 265 mg/dL.

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A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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