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 B
Explanation
Choice A reason: While knowing if the client can lie prone is useful, it is not the most critical piece of information prior to an intravenous pyelogram.
Choice B reason: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.
Choice C reason: Knowing the last time the client had a bowel movement is less critical than knowing about potential allergies to the contrast dye.
Choice D reason: While it's important to know about medication schedules, the risk of an allergic reaction to the contrast dye is a more immediate concern that could affect the safety of the procedure.
Correct Answer is A
Explanation
Choice A reason:When a client expresses concerns about medication, especially antidepressants, the nurse should encourage open communication with the healthcare provider. The provider can assess the situation, address side effects, consider adjusting the dosage, or explore alternative medications if needed.
Choice B reason: Reminding the client of the therapeutic effects is helpful for understanding the benefits of the medication, but it does not provide guidance on how to safely discontinue it.
Choice C reason:Tapering is essential for discontinuation, but it should be done under medical supervision. The nurse should first encourage the client to speak with their provider rather than assuming immediate discontinuation.
Choice D reason: While side effects may dissipate over time, this does not provide a solution for the client who wishes to stop the medication now. It is also not guaranteed that all side effects will diminish.
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