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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Related Questions
Correct Answer is C
Explanation
A. Dyspepsia:
Dyspepsia refers to discomfort or pain in the upper abdomen, often described as indigestion. It is a common symptom of peptic ulcer disease but is not as urgent as the manifestation described in option C.
B. Epigastric discomfort:
Epigastric discomfort is a common symptom of peptic ulcer disease, but the priority is to identify more severe complications, such as bleeding.
C. Hematemesis:
This is the correct answer. Hematemesis refers to the vomiting of blood, which is a serious and potentially life-threatening complication of peptic ulcer disease. It indicates active bleeding in the upper gastrointestinal tract and requires prompt medical attention.
D. Epigastric pain:
Epigastric pain is similar to epigastric discomfort and is a common symptom of peptic ulcer disease. However, the priority in the given options is to identify the more severe complication of hematemesis.
Correct Answer is B
Explanation
A. Atorvastatin: Atorvastatin is a statin medication used to lower cholesterol levels. It is not known to cause glucose intolerance.
B. Prednisone: Prednisone is a corticosteroid and can cause glucose intolerance by increasing blood glucose levels. Corticosteroids can lead to insulin resistance, impaired glucose utilization, and increased gluconeogenesis.
C. Ranitidine: Ranitidine is an H2 receptor antagonist used to reduce stomach acid production. It is not known to cause glucose intolerance.
D. Guaifenesin: Guaifenesin is an expectorant used to help loosen mucus in the airways. It is not known to cause glucose intolerance.
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