A client with signs of liver disease presents with jaundiced sclera, abdominal distension, leg swelling, and bruises in various stages of healing. Which nursing action is NOT appropriate?

Prepare for the Hurst Readiness Exam 2 with engaging quizzes, flashcards, and detailed explanations. Master your exam with confidence!

Multiple Choice

A client with signs of liver disease presents with jaundiced sclera, abdominal distension, leg swelling, and bruises in various stages of healing. Which nursing action is NOT appropriate?

A key idea here is managing fluid status and circulation in a client with liver disease and signs of fluid overload. Dangle the legs puts the legs in a dependent position, which increases venous pooling and hydrostatic pressure in the lower extremities. That can worsen peripheral edema and discomfort and may contribute to dizziness or faintness if the patient is intravascularly labile, a concern when coagulopathy is present (evidenced by bruising). So this position is not appropriate for someone with ascites and leg edema. In contrast, measuring the abdomen helps track ascites, monitoring intake and output assesses fluid balance, and obtaining a daily weight monitors changes in fluid status—these actions support safe, effective management.

A key idea here is managing fluid status and circulation in a client with liver disease and signs of fluid overload. Dangle the legs puts the legs in a dependent position, which increases venous pooling and hydrostatic pressure in the lower extremities. That can worsen peripheral edema and discomfort and may contribute to dizziness or faintness if the patient is intravascularly labile, a concern when coagulopathy is present (evidenced by bruising). So this position is not appropriate for someone with ascites and leg edema.

In contrast, measuring the abdomen helps track ascites, monitoring intake and output assesses fluid balance, and obtaining a daily weight monitors changes in fluid status—these actions support safe, effective management.

More practice questions