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

Explanation

Provide the client with warm fluids. Shivering is the body's natural response to try to warm itself up. Providing warm fluids to the client can help to increase the client's core temperature and decrease shivering.

Choice A is incorrect because a hypothermia blanket is used to reduce the client's core temperature, which is not appropriate for a client who is shivering.

Choice C is incorrect because a light blanket may not provide enough warmth for the client who is shivering.

Choice D is incorrect because the room temperature should be kept warm to prevent the client from getting colder and shivering more.

A. 36 to 48 hours. B. 24 to 36 hours. C. 12 to 24 hours. D. 1 to 2 hours.

Correct Answer is A

Explanation

36 to 48 hours. Lyme disease is caused by the bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected black-legged ticks. The tick must be attached to the skin for at least 36 to 48 hours for the bacterium to be transmitted. The nurse should advise the client to seek medical attention promptly.

Choice B is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.

Choice C is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.

Choice D is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.

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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

Which of the following interventions would be appropriate for a client who has undergone surgery for a disorder and has started shivering?

Correct Answer is B

Explanation

A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

Correct Answer is A

Explanation

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