A nurse is planning care for a client who has cirrhosis of the liver.Which of the following actions should the nurse include in the plan? (Select all that apply.)
Implement a low-sodium diet.
Administer furosemide.
Administer warfarin.
Measure the client's abdominal girth.
Encourage weight lifting during physical therapy.
Correct Answer : A,B,D
Choice A rationale
Implementing a low-sodium diet helps reduce fluid retention and ascites in clients with cirrhosis, improving their condition.
Choice B rationale
Furosemide is a diuretic that helps reduce fluid overload and ascites in clients with cirrhosis by promoting excretion of excess fluid.
Choice C rationale
Warfarin is an anticoagulant and is not typically used in the management of cirrhosis as it could increase the risk of bleeding complications, especially in clients with liver dysfunction.
Choice D rationale
Measuring the client's abdominal girth is crucial for monitoring the progression of ascites, a common complication of cirrhosis.
Choice E rationale
Encouraging weight lifting is not advisable as it can exacerbate varices and increase the risk of bleeding in clients with cirrhosis.
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Correct Answer is D
Explanation
Choice A rationale
An HbA1c level of 5.7% or below indicates normal glucose tolerance, not impaired glucose tolerance.
Choice B rationale
In type 1 diabetes mellitus, the beta cells are destroyed, and dietary changes alone cannot restore insulin production.
Choice C rationale
Type 1 diabetes mellitus is a chronic condition and is not considered reversible.
Choice D rationale
Type 1 diabetes mellitus is characterized by the autoimmune destruction of beta cells in the pancreas, leading to an absolute lack of insulin production.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Hypertension is not a typical manifestation of sepsis; sepsis usually involves hypotension.
Choice B rationale
Hypoglycemia is not a common manifestation of sepsis; hyperglycemia is more typical.
Choice C rationale
Altered mental status can occur due to the systemic inflammation and infection affecting the brain.
Choice D rationale
An elevated WBC count indicates an immune response to infection, which is a common sign of sepsis.
Choice E rationale
Vomiting can occur due to the body's response to the infection and systemic inflammation.