When performing a physical examination on a client with cirrhosis, a nurse notices that the abdomen is enlarged. Which of the following interventions should the nurse consider?
Report the condition to the physician immediately.
Provide the client with nonprescription laxatives.
Measure abdominal girth according to a set routine.
Ask the client about food intake.
The Correct Answer is C
Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.
Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.
Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.
Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.
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Correct Answer is C
Explanation
Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.
Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.
Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.
Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.
Correct Answer is {"dropdown-group-1":"B"}
Explanation
The term for severe itching is "pruritus," so the nurse should document the client's complaint as such. Pruritus can be caused by a variety of factors, including allergic reactions, skin conditions, and liver or kidney disease.
The nurse should assess the client's skin for any visible signs of irritation or rash and ask about any recent changes in medications or diet. Treatment for pruritus will depend on the underlying cause but may include topical or oral medications, cool compresses, or avoiding irritants.
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