When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
A) Report the condition to the physician immediately.
B) Measure abdominal girth according to a set routine.
C) Provide the client with nonprescription laxatives.
D) Ask the client about food intake.
B
Feedback:
If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
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