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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tremors:
Tremors or shaking is a common symptom of hypoglycemia. When blood glucose levels drop too low, the body reacts by releasing hormones like adrenaline, leading to symptoms such as tremors, shakiness, and palpitations.
B. Bradycardia:
Bradycardia, or a slow heart rate, is not typically associated with hypoglycemia. Instead, hypoglycemia tends to stimulate the release of adrenaline, which can increase heart rate.
C. Vomiting:
Vomiting is not a classic manifestation of hypoglycemia. Nausea may occur, but vomiting is more commonly associated with conditions such as hyperglycemia or diabetic ketoacidosis.
D. Fruity odor on the client’s breath:
A fruity odor on the breath is more commonly associated with diabetic ketoacidosis (DKA) in individuals with diabetes mellitus, particularly when there is an accumulation of ketones in the body. It is not a typical manifestation of hypoglycemia.
Correct Answer is B
Explanation
A. Limit fluid intake not related to meals:
While staying hydrated is important, it's generally recommended to limit fluid intake not related to meals to avoid overfilling the stomach and putting excess pressure on the lower esophageal sphincter (LES). However, this is not as specific to GERD management as the option B.
B. Avoid eating within 3 hours of bedtime:
This is a key recommendation for managing GERD. Eating close to bedtime increases the likelihood of stomach contents refluxing into the esophagus when lying down. Waiting at least 3 hours after eating before lying down can help prevent symptoms.
C. Chew on mint leaves to relieve indigestion:
Mint, including mint leaves, can relax the LES, potentially worsening GERD symptoms. It is not recommended for managing GERD.
D. Season foods with black pepper:
While black pepper itself is not a common trigger for GERD, highly spicy or peppery foods can sometimes exacerbate symptoms in individuals with GERD. It's advisable to pay attention to personal triggers and adjust the diet accordingly.
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