An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
Clear, dark amber-colored urine.
Prothrombin time within normal limits.
Decreased abdominal girth.
Improved level of consciousness.
The Correct Answer is C
A. Clear, dark amber-colored urine may indicate dehydration or concentrated urine, which does not necessarily signify improvement in liver function or treatment efficacy.
B. A prothrombin time within normal limits may indicate improved liver function; however, it is not the primary goal of the treatment plan focused on managing ascites and fluid retention in cirrhosis.
C. Decreased abdominal girth is a key indicator of progress in managing fluid retention associated with cirrhosis, as the treatment plan aims to reduce ascites through a low sodium diet and albumin infusions.
D. Improved level of consciousness is essential for overall recovery but is not the primary measure of progress related to fluid management and treatment effects in this context.
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Correct Answer is B
Explanation
A. restatement. Restatement involves repeating the patient’s words exactly, while here, the nurse is rephrasing the sentiment.
B. reflection. Reflection focuses on the patient’s feelings or experiences by paraphrasing their statement, helping the patient explore their feelings, which the nurse is doing here.
C. open-ended question. An open-ended question would be broad, allowing the patient to provide more information. This response is a restatement, not a question.
D. offering self. Offering self involves expressing a willingness to stay or support the patient, which is not demonstrated here.
Correct Answer is B
Explanation
A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.
B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.
C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.
D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.