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: Petechiae are small red or purple spots caused by bleeding into the skin, typically associated with platelet disorders, and are not a direct indicator of SBP.
Choice B reason: Increased abdominal pain is a common symptom of SBP, as the condition causes inflammation and irritation of the peritoneum, which can lead to significant discomfort.
Choice C reason: Jaundice is a sign of liver dysfunction but is not specific to SBP. It results from high levels of bilirubin in the blood and can occur in various liver diseases.
Choice D reason: Blood in emesis (vomiting) may indicate gastrointestinal bleeding, which can be a complication of cirrhosis but is not specific to SBP.
Correct Answer is A
Explanation
Choice A reason: Neutropenia, a decrease in neutrophils, is a known side effect of propylthiouracil (PTU) due to its impact on bone marrow and white blood cell production.
Choice B reason: Hyperglycemia is not a typical side effect of PTU; it is more commonly associated with medications affecting blood sugar levels.
Choice C reason: Polyuria, or excessive urination, is not a common side effect of PTU and is more often related to conditions affecting kidney function or blood glucose levels.
Choice D reason: Muscle cramps are not a direct side effect of PTU; they can be associated with various conditions, including electrolyte imbalances.
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