Which of the following is a clinical manifestation of decompensated cirrhosis? (select all that apply)
Jaundice
Hepatic encephalopathy
Ascites
Regular exercise
Correct Answer : A,B,C
Rationale:
A. Decompensated cirrhosis impairs the liver’s ability to process bilirubin, leading to yellowing of the skin and eyes.
B. Accumulation of ammonia and other toxins due to liver dysfunction can cause confusion, altered level of consciousness, and asterixis.
C. Fluid shifts into the peritoneal cavity occur due to low albumin levels and portal hypertension, causing abdominal distention.
D. While beneficial for overall health, exercise is not a clinical manifestation of cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Rationale
- Advise strict bed rest → Contraindicated
Strict bed rest is not necessary unless the patient is severely compromised; mobility is encouraged to prevent complications.
- Encourage high-sodium diet → Contraindicated
A low-sodium diet is essential to reduce fluid retention and ascites; high sodium worsens edema.
- Administer diuretics as prescribed → Anticipated
Diuretics (e.g., spironolactone, furosemide) help reduce ascites and edema.
- Monitor abdominal girth daily → Anticipated
Helps track fluid accumulation and assess effectiveness of interventions.
Correct Answer is ["D","E","F"]
Explanation
Rationale:
- Improved breathing indicates that the removal of ascitic fluid has relieved diaphragmatic pressure, allowing better lung expansion.
- Decreased abdominal pressure demonstrates that fluid removal has reduced intra-abdominal tension, improving mobility and comfort.
- Relief of abdominal discomfort is a primary goal of paracentesis, as it enhances quality of life and reduces pain caused by fluid accumulation.
- Stable vital signs and absence of respiratory distress are important for monitoring safety but are not direct measures of the procedure’s effectiveness.
- Reduced ascitic fluid volume is the mechanism of action of paracentesis, while the client’s symptomatic relief is the best indicator of clinical success.
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