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.

Answer and Explanation

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 A

Explanation

Level of consciousness is improving. The effectiveness of mannitol treatment for a client with increased intracranial pressure can be assessed through the improvement of the level of consciousness. Mannitol is an osmotic diuretic that reduces cerebral edema and intracranial pressure. It works by increasing the osmotic pressure in the bloodstream, which draws fluid out of the brain and into the bloodstream. The reduction of intracranial pressure helps improve cerebral perfusion and blood flow. Therefore, improving the client's level of consciousness is the most important assessment finding to determine the effectiveness of mannitol treatment.

B is not the correct answer because a rise in blood pressure is not an indicator of the effectiveness of mannitol treatment.

C is not the correct answer because increased urine output is a side effect of mannitol treatment and does not necessarily indicate effectiveness.

D is not the correct answer because hyperpyrexia is not a symptom that is treated with mannitol.

A. Change in bowel habits. B. Abdominal cramping when having a bowel movement. C. Daily bowel movements. D. Excess gas.

Correct Answer is A

Explanation

Change in bowel habits. Change in bowel habits, such as diarrhea, constipation, or a change in stool consistency, is a common early symptom of colon cancer. The nurse should advise clients over age 50 to report any changes in bowel habits to their primary care provider for early intervention.

Choice B is incorrect because abdominal cramping is a common symptom of irritable bowel syndrome and not necessarily an early symptom of colon cancer.

Choice C is incorrect because daily bowel movements are considered normal for some individuals and are not necessarily indicative of colon cancer.

Choice D is incorrect because excess gas is not an early symptom of colon cancer.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Correct Answer is A

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The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Correct Answer is A

Explanation

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