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?


  1. Pitting edema to lower extremities.
    • Rationale:
  2. Reddened 3cm area to sacrum.
    • Rationale:
  3. Muffled heart sounds.
    • Rationale:
  4. Jaundice
    • Rationale:



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.

Learning Outcomes

Test Taking Tip

Video Rationale