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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The assessment finding that is most important in determining which client has a higher risk for testicular cancer is cryptorchidism as an infant. Cryptorchidism, or undescended testicle(s), is a condition where one or both testicles fail to move from the abdomen into the scrotum before birth. Males with cryptorchidism are many times more likely to get testicular cancer than those with normally descended testicles. Cryptorchidism is the main risk factor for testicular cancer, while other factors such as previous STI, low sperm count, and family history of cancer are less clear or less common
Correct Answer is ["A","C","D"]
Explanation
Meniere's disease is a disorder of the inner ear characterized by episodes of vertigo, hearing loss, tinnitus, and a feeling of fullness or pressure in the ear. Nystagmus is not a common symptom of Meniere's disease. Nystagmus is a rhythmic oscillation of the eyes and may be present in other conditions such as vestibular disorders, drug toxicity, or brainstem lesions.
Choice B, nystagmus, is incorrect because although nystagmus can occur in other vestibular disorders, it is not a common symptom of Meniere's disease.
Choice E, loss of vision, is incorrect because Meniere's disease affects the inner ear and does not typically cause vision loss.
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