The nurse is assessing a patient with ascites caused by liver failure. Which finding would require immediate follow-up by the nurse?
1. asterixis
2. jaundice
3. increased abdominal girth
4. dyspnea
Correct Answer: 4
Dyspnea is the immediate priority for this patient. Asterixis or liver flap is a muscle tremor that interferes with the ability to maintain a fixed position of the extremities, causes involuntary jerking movements, and is an early sign of portal systemic encephalopathy. Jaundice is a chronic problem with liver failure and does not present an immediate threat to the patient. Increased abdominal girth is likely the result of ascites and may be contributing to the patient's shortness of breath. Although all of these symptoms should be reported to the primary healthcare provider, the nurse's immediate priority is the shortness of breath.
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