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 - 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.

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Correct Answer is B

Explanation

A. "I should place a rolled blanket along each side of my baby's head in the car seat." - Incorrect. Placing rolled blankets on each side of the baby's head is not recommended as it can increase the risk of suffocation. Infants should be positioned in the car seat without any extra padding or blankets.

B. "I should place my baby's car seat rear-facing until 6 months of age." - Correct. Rear- facing car seats are recommended for infants until they reach at least 2 years of age or until they outgrow the weight and height limits specified by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash.

C. "I should put the car seat retainer clip at the level of my baby's belly button." - Incorrect.

The retainer clip should be positioned at armpit level to secure the harness straps properly.

D. "I should position my baby's car seat at a 90-degree angle in the car." - Incorrect. Car seats should be installed at the appropriate recline angle according to the manufacturer's

instructions, which may vary depending on the specific car seat model and the child's age and size.

A. asymmetric, with variegated coloring B. scaly and red C. brown, with a wart-like texture D. firm and rubbery

Correct Answer is A

Explanation

A. Asymmetric lesions with variegated (multiple) colors are characteristic features of melanoma, a type of skin cancer. Asymmetry means one half of the lesion does not match the other half in size, shape, or color.

B. Scaly and red lesions may indicate other skin conditions such as eczema or psoriasis but are not specific to skin cancer.

C. Brown lesions with a wart-like texture may indicate seborrheic keratosis, a benign skin growth, rather than skin cancer.

D. Firm and rubbery lesions may indicate benign skin tumors such as fibromas or lipomas, rather than skin cancer.

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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

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