Gastrointestinal Question #12
The nurse is assessing a client with a history of cirrhosis and receives a report that the abdomen enlarged by 3cm over the past 24 hours. The nurse contacts the health care provider because of which finding?
- Pitting edema to lower extremities.
- Reddened 3cm area to sacrum.
- Muffled heart sounds.
Muffled heart sounds on auscultation indicate fluid build-up in the pericardial space which may lead to cardiac tamponade. The client may also have jugular vein distention and hypotension. Options A and B are incorrect because although edema and changes in skin integrity should be reported, a muffled heart sound is more emergent. Option D is incorrect since jaundice is expected.
Test Taking Tip