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 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.

A. "I can store unopened bottles of insulin in the freezer." B. "My morning blood glucose should be between 200 and 230," C. "I should eat a snack half an hour before playing soccer." D. "I should not take my regular insulin when I am sick."

Correct Answer is C

Explanation

A. Storing unopened bottles of insulin in the freezer is incorrect. Insulin should be stored in the refrigerator, and freezing can damage the insulin.

B. Having a morning blood glucose level between 200 and 230 is too high. The target range for fasting blood glucose is generally lower, and elevated levels may indicate the need for adjustment in insulin or other medications.

C. Eating a snack half an hour before playing soccer is a correct understanding. This helps prevent hypoglycemia during physical activity. Physical activity can lower blood glucose levels, and a pre-activity snack can provide additional carbohydrates to prevent low blood sugar.

D. Not taking regular insulin when sick is incorrect. In fact, insulin needs may increase during illness, and it is usually recommended to continue taking insulin even when sick. Adjustments to the insulin regimen may be needed under the guidance of healthcare providers.

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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.)

Nursing Test Bank

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