A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Decrease the client's carbohydrate intake.

Increase the client's saturated fat intake.

Decrease the client's fluid intake.

Increase the client's sodium intake.

Answer and Explanation

The Correct Answer is C

Choice A reason : Decreasing the client's carbohydrate intake is not typically a priority intervention for cirrhosis and ascites. While managing overall nutrition is important, carbohydrates are a necessary component of a balanced diet and provide essential energy¹.

Choice B reason : Increasing the client's saturated fat intake is not recommended in cirrhosis and ascites. Saturated fats can contribute to fatty liver disease and worsen liver function. A diet low in saturated fats and high in omega-3 fatty acids is generally advised¹.

Choice C reason : Decreasing the client's fluid intake is a key intervention for managing ascites in cirrhosis. Ascites is the accumulation of fluid in the peritoneal cavity, and reducing fluid intake can help manage this condition. The goal is to prevent further fluid accumulation and reduce the risk of complications such as spontaneous bacterial peritonitis¹².

Choice D reason : Increasing the client's sodium intake is not advised for cirrhosis and ascites. Sodium can cause the body to retain water, exacerbating fluid accumulation in the abdomen. A low-sodium diet is typically recommended to help control ascites¹.

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Correct Answer is D

Explanation

Choice A reason : Tarry stools, also known as melena, can be a sign of gastrointestinal bleeding, which may occur in cirrhosis due to the development of esophageal varices. However, it is not a direct symptom of cirrhosis itself but rather a complication that can arise from the condition¹.

Choice B reason : Blood in the urine is not a typical finding associated with cirrhosis. While cirrhosis can lead to problems with kidney function, hematuria is not a direct symptom of liver disease and may indicate other urological conditions¹.

Choice C reason : Moist skin is not commonly associated with cirrhosis. Patients with cirrhosis often experience skin changes, but these typically include jaundice, bruising, and spider angiomas, not increased moisture of the skin¹.

Choice D reason : Spider angiomas are a common finding in cirrhosis. They are small, spider-like capillaries visible under the skin and are caused by the increased estrogen levels that occur due to the liver's inability to metabolize hormones properly. They are most often found on the face, neck, upper chest, and arms¹².

A. "A headache is an expected side effect of the medication." B. "A headache is an indication of an allergy to the medication." C. "A headache is likely due to the anxiety about the chest pain." D. "A headache indicates tolerance to the medication."

Correct Answer is A

Explanation

Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.

Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.

Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.

Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.

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A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

Correct Answer is D

Explanation

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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