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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Gastroesophageal reflux disease (GERD) is a condition where stomach acid frequently flows back into the esophagus, causing discomfort. Certain lifestyle habits and diet can trigger or worsen GERD symptoms. Alcohol and caffeine are among the substances that can aggravate
GERD123. They can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. Therefore, reducing or avoiding alcohol and caffeine can help manage GERD symptoms.
Choice B rationale
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can cause or worsen GERD symptoms. It can irritate the esophagus and stomach lining, leading to heartburn and other GERD symptoms. Therefore, it’s not advisable to take aspirin if you have GERD12.
Choice C rationale
While it’s important to avoid mercury-containing foods due to their potential health risks, there’s no specific link between these foods and GERD12. GERD is primarily triggered by foods that relax the lower esophageal sphincter, cause stomach distension, or irritate the esophagus. Mercury-containing foods do not fall into these categories.
Choice D rationale
Lying down after eating can indeed increase the onset of GERD123. When you lie down, it’s easier for stomach acid to backflow into the esophagus. This is why it’s recommended to wait at least 2-3 hours after eating before lying down.
Correct Answer is A
Explanation
Choice A rationale
Sleep problems are a common non-gastrointestinal symptom associated with IBS345. These can include difficulty falling asleep, frequent awakenings during the night, and feeling unrefreshed upon waking.
Choice B rationale
General muscle aches are not typically associated with IBS. While some people with IBS may experience discomfort or pain in various parts of their body, these symptoms are not usually described as muscle aches.
Choice C rationale
Paresthesias, or abnormal sensations such as tingling or prickling, are not typically associated with IBS345.
Choice D rationale
Restlessness is not typically associated with IBS. However, some people with IBS may experience increased anxiety or stress, which could potentially lead to feelings of restlessness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.