While performing a physical examination on a client with cirrhosis, which of the following interventions should the nurse report immediately to the physician?

Pode the client with non-prescription laxatives.

Measure abdominal girth according to a set routine.

Ask the client about food intake.

Check for signs of hepatic encephalopathy.

Answer and Explanation

The Correct Answer is A

Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.

Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.

Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.

Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.

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Correct Answer is ["B","C","D","E"]

Explanation

"Temperature regulation," "Protection," "Sensory processing," and "Chemical synthesis." These are all functions of the skin that the nurse should expect students to identify during a group discussion about the skin's functions. Choice A, "Metabolism," is not a primary function of the skin, although the skin does play a role in the synthesis of vitamin D, which can impact metabolism.

A. Palpate gently without repeated attempts. B. Not palpate the thyroid and just listen for a bruit. C. Palpate firmly in order to feel the thyroid gland. D. Continue to palpate the gland until it is felt for enlargement.

Correct Answer is A

Explanation

Palpate gently without repeated attempts. Palpating the thyroid gland can stimulate the release of thyroid hormone, which can result in a thyroid storm, a potentially life-threatening condition characterized by a rapid heart rate, fever, and high blood pressure. Therefore, the nurse should be careful not to overstimulate the thyroid gland.

Not palpating the thyroid and just listening for a bruit (B) is not a sufficient assessment of the thyroid gland. Palpating the gland firmly in order to feel it for enlargement (C) can be too stimulating and increase the risk of thyroid hormone release. Continuing to palpate the gland until it is felt for enlargement (D) is not necessary and may result in overstimulation of the gland.

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While performing a physical examination on a client with cirrhosis, which of the following interventions should the nurse report immediately to the physician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing instructor is having a group discussion about the functions of the skin prior to reviewing common skin disorders. The instructor is pleased when the students answer (SATA).

Correct Answer is ["B","C","D","E"]

Explanation

The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?

Correct Answer is A

Explanation

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