A nurse is caring for a client in an acute care setting.

Exhibits

Complete the following sentence by using the list of options.

The client is at risk for

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as evidenced by the client's 

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A. Restrict the client's sodium intake
One of the common complications of cirrhosis and liver disease is ascites (fluid accumulation in the abdomen), and hyponatremia (low sodium) may develop due to the body's altered fluid balance. Sodium restriction is a key part of managing ascites and preventing further fluid buildup.
B. Provide frequent rest periods for the client
Fatigue and weakness are common symptoms of liver disease and cirrhosis. The client is likely experiencing decreased energy levels due to liver dysfunction, so it is important to provide frequent rest periods to help prevent further fatigue and promote overall well-being.
C. Assess the client's level of orientation
Disorientation to time and changes in mental status are common in clients with liver disease, particularly due to the development of hepatic encephalopathy, a condition where toxins (like ammonia) accumulate in the blood and affect brain function.
D. Instruct the client to avoid blowing their nose forcefully
This action is typically suggested for clients at risk for bleeding (e.g., those with low platelet counts or clotting disorders). Although the client does have thrombocytopenia (low platelet count), there is no evidence in the provided data that the client is at immediate risk for epistaxis (nosebleeds).
E. Place the client on a low-carbohydrate diet
Clients with liver disease typically benefit from a high-calorie, high-protein diet to support healing and provide energy. A low-carbohydrate diet is not indicated unless there are other factors like diabetes or fatty liver disease, which is not suggested by the information provided.
F. Place the client under contact isolation
Contact isolation is generally used to prevent the spread of infectious diseases that are transmitted through direct contact with the patient or their environment (e.g., MRSA, C. difficile). There is no
indication that this client has a contagious infection that would require isolation. The client’s symptoms are more indicative of liver disease and complications of cirrhosis, rather than an infectious condition that would require isolation.
G. Advise the client to avoid the use of soap and alcohol-based lotions
Clients with liver disease often experience dry skin and pruritus (itching), which can be aggravated by harsh soaps and alcohol-based lotions. The yellowing of the sclera (jaundice) and itching (pruritus) are symptoms commonly seen in liver dysfunction, and using gentle skin care products without harsh chemicals will help minimize irritation and soothe the skin.

A. When using crutches, the client should position both hands on the grips with the elbows slightly flexed for proper support and balance.
B. In the three-point gait, the crutches and the injured leg move together, followed by the uninjured leg. The stronger leg does not move first.
C. The client should not lean on the axillary crutch pads as it can cause nerve damage. Body weight should be supported through the hands and arms.
D. When going up stairs, the uninjured leg should move first, followed by the crutches and the affected leg.