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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?

A.

Clear, dark amber-colored urine.

B.

Prothrombin time within normal limits.

C.

Decreased abdominal girth.

D.

Improved level of consciousness.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

A. Does not include humor.
Humor can be an appropriate part of the nurse-patient relationship when used sensitively to ease tension or build rapport.

B. Continues after discharge.
The therapeutic relationship typically ends upon discharge, respecting professional boundaries.

C. Focuses on the assessed patient health problems.
The nurse-patient relationship centers on addressing the patient’s identified health issues and providing support, making this option accurate.

D. Focuses on the nurse's ability to build rapport.
While rapport is important, the primary goal is to address the patient’s health needs, not just rapport-building alone.

Correct Answer is D

Explanation

A. While hematocrit levels provide information about blood volume status, they are not directly relevant to infection status or wound healing in burn patients.

B. Blood pH levels can indicate acid-base imbalances, but they do not specifically inform the nurse about the presence of infection.

C. Platelet count is important for assessing coagulation and bleeding risks, but it does not provide direct information regarding infection.

D. White blood cell (WBC) count is critical in assessing for infection, as an elevated WBC count can indicate the presence of an infection, particularly in a client with significant burns who is at increased risk for sepsis.

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