A nurse is assessing an elderly patient who has just been admitted to the medical-surgical unit with significant abdominal ascites.
The patient is alert and oriented, walks independently at home, and usually uses a cane but forgot to bring it to the hospital.Which measures should the nurse prioritize?
Implementing a bleeding precaution protocol
Implementing a skin safety protocol
Implementing a sodium restriction diet
Implementing a fall risk protocol
The Correct Answer is D
Choice A rationale
While bleeding precautions are important in certain conditions, they may not be the priority for a patient with significant abdominal ascites. Ascites, the accumulation of fluid in the peritoneal cavity, is often caused by liver disease such as cirrhosis.
Choice B rationale
Skin safety protocols are important for all patients, but they may not be the priority in this case. Ascites can cause discomfort and other complications, but it does not directly cause skin problems.
Choice C rationale
A sodium restriction diet can be beneficial for patients with ascites, as it can help reduce fluid accumulation. However, this measure may not be the priority in this case.
Choice D rationale
Implementing a fall risk protocol should be prioritized. The patient’s significant abdominal ascites could affect their balance and mobility, increasing their risk of falls. Furthermore, the patient usually uses a cane for support but forgot to bring it to the hospital, further increasing their fall risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Monitoring for changes in the color of urine to maroon or red is not typically associated with peptic ulcers. This could be a sign of other conditions such as urinary tract infections, kidney stones, or certain medications.
Choice B rationale
Unintentional weight gain is not a common symptom of peptic ulcers. In fact, some people with peptic ulcers may experience weight loss due to discomfort while eating or a decrease in appetite.
Choice C rationale
The appearance of ecchymosis (bruising) on the sides of the abdomen or pelvic areas is not a typical symptom or concern with peptic ulcers. This could be a sign of trauma, certain medications, or other medical conditions.
Choice D rationale
One of the symptoms of a peptic ulcer can be changes in the color of the stool, particularly if it becomes dark or black. This can be a sign of bleeding in the gastrointestinal tract, which can occur with peptic ulcers. Therefore, patients should be advised to monitor for this symptom and seek medical attention if it occurs.
Correct Answer is B
Explanation
Choice A rationale
While chronic exposure to UV rays can cause skin dryness, it does not decrease the water content of the skin20. Skin dryness is more of a symptom rather than a risk factor for skin cancer20.
Choice B rationale
Chronic exposure to UV rays can cause an error in the skin’s genetic code20. This can lead to the development of skin cancer, as the damaged DNA can lead to uncontrolled cell growth20.
Choice C rationale
Increased blood flow to the skin is not a direct result of chronic exposure to UV rays20. While UV rays can cause skin redness and inflammation, these are not directly linked to an increased risk of skin cancer20.
Choice D rationale
Chronic exposure to UV rays does not cause degeneration of elastic fibers in skin tissue20. While UV rays can cause skin aging and wrinkles, these are not direct risk factors for skin cancer20. Diabetic retinopathyDiabetic retinopathy Explore
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