A nurse is caring for a client who has been admitted to the hospital.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Crossing the arms across the chest is not a recommended practice in postmortem care. The arms should be placed at the sides of the body or in a natural position.
B. Dentures should be left in the mouth unless there are specific cultural or legal reasons to remove
them. The client’s appearance should be as natural as possible.
C. Placing the client in a high-Fowler's position is not recommended after death. It can be uncomfortable and may distort the body.
D. Holding the client’s eyes shut is important to prevent the eyes from remaining open after death. This is commonly done as part of postmortem care to make the body appear more peaceful.
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