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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Bradycardia is not typically associated with gastrointestinal perforation. Instead, tachycardia may be observed due to the body's response to a potential emergency or shock.

B. Hyperactive bowel sounds are not typically associated with gastrointestinal perforation. In fact, bowel sounds may decrease or become absent in severe cases of peritonitis or abdominal emergencies.

C. Increased blood pressure is not typically associated with gastrointestinal perforation. Hypotension may be observed due to hypovolemia resulting from fluid leakage into the peritoneal cavity.

D. Sudden abdominal pain is a key clinical manifestation of gastrointestinal perforation. The perforation of the stomach or intestines allows the contents to leak into the abdominal cavity, leading to peritonitis. Sudden and severe abdominal pain is a hallmark symptom, often described as sharp, stabbing, and constant.

A. "Wear compression stockings daily." B. "Have an eye examination once per year." C. "Maintain stable blood glucose levels." D. "Examine your feet carefully every day."

Correct Answer is C

Explanation

A. "Wear compression stockings daily":

Compression stockings are not directly related to preventing the complications of retinopathy and nephropathy in diabetes. They are more commonly recommended for managing conditions like venous insufficiency and preventing blood clots.

B. "Have an eye examination once per year":

While regular eye examinations are important for monitoring and early detection of diabetic retinopathy, maintaining stable blood glucose levels is more directly related to preventing the progression of retinopathy.

C. "Maintain stable blood glucose levels":

This is the correct instruction. Stable blood glucose levels are crucial in preventing and minimizing the long-term complications of diabetes, including retinopathy (damage to the retina) and nephropathy (kidney damage). Consistent blood glucose control is key to reducing the risk of complications.

D. "Examine your feet carefully every day":

Daily foot examinations are essential for preventing diabetic foot complications, including ulcers and infections. While important for overall diabetes management, foot care is not specifically directed at preventing retinopathy and nephropathy.

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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.)

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