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
The Correct Answer is A
A.
A. Monitor for abdominal ascites - Ascites is a common complication of cirrhosis due to portal hypertension and decreased albumin production. Monitoring for abdominal distention and fluid
accumulation is essential for assessing the progression of cirrhosis and implementing appropriate interventions.
B. Implement a low-carbohydrate diet - While dietary modifications may be necessary for clients with cirrhosis, such as reducing sodium intake, implementing a low-carbohydrate diet is not typically a primary intervention for cirrhosis.
C. Review serum amylase levels - Serum amylase levels are typically assessed to diagnose pancreatitis, which is not directly related to cirrhosis unless complications such as alcoholic pancreatitis are present.
D. Place warm compresses on areas of pruritus - Pruritus (itching) is a common symptom of liver disease, including cirrhosis, due to bile salt accumulation. While warm compresses may provide
temporary relief, they do not address the underlying cause of pruritus in cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. "Notify your provider if you experience muscle weakness." - Muscle weakness can be a sign of digoxin toxicity and should be reported to the provider immediately.
B. "Report a weight gain of one-half pound per day." - While weight gain can indicate fluid retention, it is not a specific symptom of digoxin toxicity.
C. "Expect this medication to increase your blood pressure." - Digoxin is not typically associated with increasing blood pressure.
D. "You will need to take a diuretic while taking this medication." - Diuretics are not typically required with digoxin unless there are specific indications for their use.
Correct Answer is D
Explanation
A. A metallic taste in the mouth is a common side effect of the contrast dye used in IV urography procedures and is not typically a cause for concern.
B. Abdominal fullness may occur due to the administration of fluids during the procedure and is not usually a priority finding unless it persists or is severe.
C. Feeling flushed and warm may be a transient reaction to the contrast dye and does not typically require immediate intervention unless accompanied by other symptoms.
D. Swollen lips could indicate an allergic reaction to the contrast dye, which can progress rapidly and potentially lead to a severe reaction such as anaphylaxis. This is the priority finding requiring immediate attention.
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