Medical Surgical Liver Cirrhosis #4

Question

The nurse is assessing a client with a history of cirrhosis and receives a report that the abdomen enlarged by 3 cm over the past 24 hours. The nurse contacts the health care provider because of which priority finding?

Answers

  1. Pitting edema to lower extremities.
    • Rationale:

      While pitting edema should be reported, a muffled heart sound is more emergent. Muffled heart sounds on auscultation indicate fluid build-up in the pericardial space which may lead to cardiac tamponade. Therefore, this is the priority data the nurse reports to the healthcare provider.

  2. Reddened 3 cm area to sacrum.
    • Rationale:

      While changes in skin integrity should be reported, a muffled heart sound is more emergent. Muffled heart sounds on auscultation indicate fluid build-up in the pericardial space which may lead to cardiac tamponade. Therefore, this is the priority data the nurse reports to the healthcare provider.

  3. Muffled heart sounds.
    • Rationale:

      Muffled heart sounds on auscultation indicate fluid build-up in the pericardial space. This may lead to cardiac tamponade which is potentially life-threatening; therefore, this is the priority data the nurse reports to the healthcare provider.

  4. Jaundice.
    • Rationale:

      Jaundice is expected for this client; therefore, this finding does not require the nurse to contact the healthcare provider. Muffled heart sounds on auscultation indicate fluid build-up in the pericardial space which may lead to cardiac tamponade. Therefore, this is the priority data the nurse reports to the healthcare provider.

Overview

Cirrhosis is a late stage of scarring (i.e., fibrosis) of the liver caused by many different liver diseases and conditions (e.g., hepatitis, chronic alcoholism).

Explanation

Learning Outcomes

Cirrhosis is a late stage of scarring (i.e., fibrosis) of the liver caused by many different liver diseases and conditions (e.g., hepatitis, chronic alcoholism). Increased abdominal girth is indicative of ascites (i.e., abdominal swelling caused by an accumulation of fluid) and is a complication associated with cirrhosis. 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.

Test Taking Tip

Consider the ABCs (airway, breathing, circulation) to answer this question correctly.

Video Rationale