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 C
Explanation
Choice A rationale
Dysarthria, or difficulty articulating speech, is not a symptom of GERD. GERD primarily affects the digestive system, causing symptoms such as heartburn and regurgitation.
Choice B rationale
Dysesthesia, or abnormal sensation, is not a symptom of GERD. GERD does not typically cause sensory disturbances.
Choice C rationale
This is the correct answer. Dyspepsia, or indigestion, is a common symptom of GERD. It can manifest as discomfort or pain in the stomach or chest, a feeling of fullness, or problems with belching or gas.
Choice D rationale
Dyspnea, or shortness of breath, is not a typical symptom of GERD. While severe GERD can sometimes cause respiratory symptoms due to aspiration of stomach contents or irritation of the airways, it is not a common or primary symptom.
Correct Answer is D
Explanation
Choice A rationale
While a 25-year-old planning to lose 20 pounds after childbirth may have increased nutritional needs, they would not typically be considered at higher risk for malnutrition unless there were other factors such as inadequate diet or certain health conditions.
Choice B rationale
A 65-year-old who recently underwent hernia surgery might have temporary changes in diet or appetite related to the surgery, but would not typically be at high risk for malnutrition unless there were other ongoing issues such as poor diet, difficulty eating, or a chronic health condition.
Choice C rationale
A 70-year-old who has been fasting since midnight in preparation for a colonoscopy would not typically be at risk for malnutrition from this short-term fast. However, if they had ongoing issues with diet, appetite, or a chronic health condition, they could potentially be at risk.
Choice D rationale
A 55-year-old who has been consuming alcohol for 35 years is at higher risk for malnutrition. Alcohol can interfere with the body’s ability to absorb and use nutrients, and individuals with long-term heavy alcohol use may also have other lifestyle factors that increase their risk for malnutrition.
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.