Question

A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan?

A) Measure the client's abdominal girth daily.
B) Check mental status once daily.
C) Provide a daily intake of 4 g of sodium for the client.
D) Assess the client's breath sounds every 12 hr.

Answer 1

When developing a plan of care for a client with cirrhosis and ascites, the nurse should include measuring the client's abdominal girth daily, checking mental status once daily, and encouraging a low-sodium diet to manage fluid retention.

Step-by-step explanation:

When developing a plan of care for a client with cirrhosis and ascites, the nurse should include the following interventions:

1. Measure the client's abdominal girth daily: This helps monitor the amount of fluid accumulation in the abdomen and allows for early detection of worsening ascites.
2. Check mental status once daily: This is important because hepatic encephalopathy, a complication of cirrhosis, can affect brain function and lead to changes in mental status.
3. Provide a daily intake of 4 g of sodium for the client: This is not recommended. In fact, sodium restriction is essential for patients with ascites to help manage fluid retention. The nurse should encourage a low-sodium diet to reduce fluid buildup.

Assessing the client's breath sounds every 12 hours is not directly related to the care of a client with cirrhosis and ascites, so it would not be included in the plan of care.