A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)
Encourage weight lifting during physical therapy
Measure the client's abdominal girth.
Administer warfarin.
Administer furosemide.
Implement a low-sodium diet.
Correct Answer : B,D,E
A. Encourage weight lifting during physical therapy:
Encouraging weight lifting or strenuous physical activities might not be advisable for individuals with advanced cirrhosis. Engaging in intense physical activity could potentially strain the liver or increase the risk of injury or bleeding, which is already heightened in individuals with cirrhosis.
B. Measure the client's abdominal girth:
Monitoring the client's abdominal girth is essential because cirrhosis can lead to the accumulation of fluid in the abdomen, known as ascites. Changes in abdominal girth can indicate the progression or resolution of ascites, guiding treatment and interventions.
C. Administer warfarin:
Administering warfarin, an anticoagulant, might not be ideal in cirrhosis due to the increased risk of bleeding. Liver dysfunction in cirrhosis can impair the production of clotting factors, increasing the risk of bleeding complications.
D. Administer furosemide:
Furosemide, a diuretic, can be utilized in managing ascites by promoting the elimination of excess fluid. However, its use requires careful monitoring, considering the electrolyte balance and potential adverse effects, especially in individuals with liver impairment.
E. Implement a low-sodium diet:
A low-sodium diet is crucial in managing cirrhosis-related complications, particularly ascites and edema. Sodium restriction helps reduce fluid retention, lessening the burden on the liver and alleviating symptoms associated with fluid accumulation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Insulin glargine does not have a duration of 3 to 6 hours. This duration of action is much shorter than the actual duration of insulin glargine.
B. Insulin glargine does not have a duration of 14 to 22 hours. This duration is shorter than the typical duration of action for insulin glargine.
C. Insulin glargine, a long-acting insulin, has a duration of action that lasts approximately 24 to 36 hours. It provides a slow and steady release of insulin, offering a relatively consistent blood sugar-lowering effect over an extended period.
D. Insulin glargine does not have a duration of 6 to 10 hours. This duration is shorter than the actual duration of action for insulin glargine.
Correct Answer is A
Explanation
A. Fatty stools:
Obstruction of the common bile duct can result in impaired bile flow, leading to a decrease in bile salts reaching the intestine. This can result in the malabsorption of fats, causing fatty or greasy stools (steatorrhea).
B. Tenderness in the left upper abdomen:
Tenderness in the left upper abdomen might be more commonly associated with conditions like splenic issues or stomach problems rather than an obstruction of the common bile duct.
C. Straw-colored urine:
Straw-colored urine is typical of well-hydrated individuals and might not directly correlate with an obstruction of the common bile duct.
D. Ecchymosis of the extremities:
Ecchymosis (bruising) of the extremities is not typically associated with an obstruction of the common bile duct resulting from chronic cholecystitis.
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