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A nurse is caring for a client who has been admitted to the hospital.

Exhibits

Select the 5 actions the nurse should take.

Restrict the client's sodium intake.

Provide frequent rest periods for the client.

Assess the client's level of orientation.

Instruct the client to avoid blowing their nose forcefully.

Place the client on a low-carbohydrate diet.

Place the client under contact isolation.

Advise the client to avoid the use of soap and alcohol-based lotions.

Answer and Explanation

Correct Answer : A,B,C,G

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.

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Correct Answer is B

Explanation

A. Postural drainage should ideally be done after meals to reduce the risk of vomiting.
B. Holding the hand flat during percussions helps distribute the force evenly and prevents injury to the
child’s ribcage.
C. The procedure may need to be performed more than twice daily, depending on the child's condition.
D. A bronchodilator is typically administered before the procedure, not after, to help open the airways and improve the effectiveness of drainage.

A. Steatorrhea B. Weight loss C. Diarrhea D. Fever E. Anemia

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,C"}}

Explanation

Steatorrhea (Fatty stool) Consistent with Crohn's Disease

Steatorrhea refers to the presence of fat in the stool, which often results in fatty, foul-smelling stools. This is seen in Crohn's disease due to malabsorption in the small intestine (especially in the ileum), where fat is not absorbed properly. Ulcerative colitis typically affects the colon, not the small intestine, and does not usually result in steatorrhea. Diverticulitis is an infection or inflammation of diverticula in the colon and is not associated with steatorrhea.

Weight Loss

Consistent with Ulcerative Colitis and Crohn's Disease

Weight loss is a common finding in both ulcerative colitis and Crohn’s disease. In Crohn's disease, weight loss occurs due to malabsorption and inflammatory damage in the gastrointestinal tract. In ulcerative colitis, weight loss can occur during flare-ups due to poor nutrient absorption and inflammation of the colon. Diverticulitis may cause weight loss if it leads to complications like chronic inflammation, but it is not a primary or typical symptom.

Diarrhea

Consistent with Ulcerative Colitis, Diverticulitis and Crohn's Disease

Diarrhea is a hallmark symptom of both ulcerative colitis and Crohn's disease. In ulcerative colitis, diarrhea is usually accompanied by blood and mucus, as the disease primarily affects the colon. In Crohn’s disease, diarrhea is also common, but it may be more chronic and associated with areas of the GI tract other than the colon, such as the small intestine. Diverticulitis typically presents with abdominal pain, fever, and changes in bowel habits- diarrhea in 25% of patients.

Fever

Consistent with Ulcerative Colitis, Diverticulitis, and Crohn's Disease

Fever can be seen in all three conditions, though it is more commonly associated with diverticulitis during an acute infection of the diverticula. Fever in ulcerative colitis and Crohn’s disease can occur during active inflammation or flare-ups, especially if there is significant bowel involvement or complications like perforation or abscess. In Crohn's disease, fever is often seen in more severe or complicated disease phases, but it is not always present. Diverticulitis often presents with fever, especially in the case of an infection or abscess formation.

Anemia

Consistent with Ulcerative Colitis and Crohn's Disease

Anemia can be seen in both ulcerative colitis and Crohn's disease. In ulcerative colitis, chronic blood loss due to inflammation and ulceration in the colon can lead to iron-deficiency anemia. In Crohn's disease, anemia can result from chronic inflammation, bleeding, or malabsorption of nutrients (like iron, vitamin B12, or folic acid). Diverticulitis may also cause anemia, particularly if there is significant bleeding, but it is not a hallmark feature like it is in ulcerative colitis and Crohn’s disease.

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A nurse is caring for a client who has been admitted to the hospital. Exhibits Select the 5 actions the nurse should take.

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Correct Answer is B

Explanation

A nurse is caring for a client. Exhibits For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,C"}}

Explanation

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A nurse is caring for a client who has been admitted to the hospital.

Exhibits

Select the 5 actions the nurse should take.