Practice Question # 847.
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Question 1 of 1
The nurse is caring for a client with cirrhosis of the liver. Which is the best method to use for determining that the client has ascites?Correct
Answer C is correct.
Rationale: A measurement that reveals a numerical value would be the most accurate to detect changes in the size of the abdomen. Answers A, B, and D are less objective, so they are incorrect.Incorrect
Answer C is correct.
Rationale: A measurement that reveals a numerical value would be the most accurate to detect changes in the size of the abdomen. Answers A, B, and D are less objective, so they are incorrect.
Cirrhosis What to look for:
Cirrhosis affects many body systems. Assess the patient for these signs and symptoms:
- GI (usually early and vague) — anorexia, indigestion, nausea and vomiting, constipation or diarrhea, dull abdominal ache
- respiratory — pleural effusion, limited thoracic expansion
- central nervous system — progressive signs and symptoms of hepatic encephalopathy, including lethargy, mental changes, slurred speech, asterixis (flapping tremor), peripheral neuritis, paranoia, hallucinations, extreme obtundation, coma
- hematologic — bleeding tendencies (nosebleeds, easy bruising, bleeding gums), anemia
- endocrine — testicular atrophy, menstrual irregularities, gynecomastia, loss of chest and axillary hair
- skin — severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema, possibly j aundice
- hepatic — jaundice, hepatomegaly, ascites, edema of the legs
- miscellaneous — musty breath, enlarged superficial abdominal veins, muscle atrophy, pain in the right upper abdominal quadrant that worsens when the patient sits up or leans forward, palpable liver or spleen, temperature of 101º to 103º F (38.3º to 39.4º C), bleeding from esophageal varices.