Assessment of a client with cirrhosis reveals a distended abdomen, weight gain, and dyspnea. Based on this information, what interventions would the nurse include in this client's plan of care?
Implement a sodium restriction.
Encourage fluids.
Check lipase level.
Administer pancrealipase.
The Correct Answer is A
Choice A reason: Sodium restriction is a standard intervention in the management of cirrhosis, particularly when there is fluid retention leading to a distended abdomen (ascites) and weight gain.
Choice B reason: Encouraging fluids would not be appropriate for a client with cirrhosis who is already experiencing fluid overload, as indicated by a distended abdomen and weight gain.
Choice C reason: Checking lipase levels is associated with pancreatic function and would not be a direct intervention based on the symptoms of cirrhosis presented.
Choice D reason: Pancrealipase is used to aid digestion in patients with pancreatic insufficiency and is not related to the management of cirrhosis symptoms such as ascites and dyspnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Monitoring heart rate and rhythm is important in heart failure management, but it does not directly reflect the effectiveness of enalapril and furosemide, which are primarily used to control blood pressure and reduce fluid overload, respectively.
Choice B reason: Auscultating lung fields can reveal the presence of fluid, indicating pulmonary edema, a common complication of left-sided heart failure. Checking BP is essential as enalapril is an ACE inhibitor that lowers BP, and furosemide can also affect BP through its diuretic effect.
Choice C reason: Assessing for JVD can indicate right-sided heart failure, which may develop secondary to left-sided heart failure. However, it is not the primary assessment for the effectiveness of enalapril and furosemide.
Choice D reason: Checking peripheral pulses is a general assessment and, while important, it does not specifically evaluate the effectiveness of the medications in question.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Resting tremor is a classic symptom of Parkinson's disease and is one of the primary diagnostic criteria.
Choice B reason : Limited range of motion is not specific to Parkinson's disease and can be caused by various conditions.
Choice C reason : Hypertension is not a diagnostic criterion for Parkinson's disease.
Choice D reason : Difficulty rising to stand is associated with the bradykinesia seen in Parkinson's disease, making it a relevant symptom for diagnosis.
Choice E reason : Diarrhea is not typically associated with Parkinson's disease and is not a diagnostic criterion.
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