The nurse assesses a patient who has cirrhosis secondary to liver failure. Which finding would require immediate follow-up by the nurse?
1. Asterixis
2. Jaundice
3. Increased abdominal girth
4. Dyspnea
4
Rationale 1: Asterixis, or liver flap, is an early sign of portal systemic encephalopathy. Asterixis should be reported and evaluated but is not the priority.
Rationale 2: Jaundice is a chronic problem with liver failure and does not present an immediate threat to the patient.
Rationale 3: Increased abdominal girth is an expected finding with cirrhosis.
Rationale 4: Dyspnea is the priority for this patient. The nurse should use ABCs to prioritize. Dyspnea can occur from pressure on the diaphragm.
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