While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?
Decreased bowel sounds.
Increased respiratory rate.
Increased abdominal girth.
Decreased level of consciousness.
The Correct Answer is C
Choice A reason: Decreased bowel sounds may be associated with cirrhosis due to altered digestion but do not directly correlate with weight gain.
Choice B reason: An increased respiratory rate can be a sign of many conditions, including fluid overload, but it is not a specific indicator of weight gain due to fluid accumulation.
Choice C reason: Increased abdominal girth is a common sign of ascites, which is fluid accumulation in the abdomen often seen in cirrhosis, correlating with the reported weight gain.
Choice D reason: Decreased level of consciousness may indicate hepatic encephalopathy in cirrhosis patients but does not directly correlate with the weight gain described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.
Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.
Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.
Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.
Correct Answer is D
Explanation
Choice A reason: Asking if there is a particular reason why the parent thinks it's their fault may inadvertently validate feelings of self-blame, which is not helpful in this sensitive situation.
Choice B reason: While reassuring the parent they did nothing wrong is true, it may not address the emotional support the parent needs at this moment.
Choice C reason: Promising a full recovery with surgery may be misleading and give false hope, as outcomes can vary and myelomeningocele often results in some degree of impairment.
Choice D reason: Acknowledging the parent's feelings and the difficulty of the situation provides emotional support and validation without assigning blame or making promises about the outcome.
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