Question

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider?

a) Yellowing of the skin and eyes
b) Elevated blood pressure
c) Swelling of the ankles
d) Increased abdominal girth

Answer 1

The priority for the nurse to report is increased abdominal girth, indicating possible ascites, a severe complication of cirrhosis.

Step-by-step explanation:

When assessing a client who has cirrhosis, the priority for the nurse to report to the provider is increased abdominal girth. This could be an indication of ascites, which is fluid accumulation in the abdominal cavity and is the most common complication of cirrhosis.

Ascites is associated with a poor quality of life and an increased risk of infection. While the other symptoms listed are also important and related to liver dysfunction — such as jaundice manifesting as yellowing of the skin and eyes, and swelling of the ankles due to edema — increased abdominal girth may suggest acute decompensation of cirrhosis and thus requires immediate attention.