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A nurse is caring for an elderly patient with significant ascites due to end-stage liver disease. Which of the following precautions should the nurse include in the patient’s care plan?

“An increased weight in the abdomen can lead to problems with getting comfortable when lying down, therefore, have extra pillows in bed.”.

“Due to the increased weight in the abdomen, it is advised that you do not wear undergarments as they will not fit.”.

“The increased weight in your abdomen will mean that you can no longer exercise due to the strain on your heart.”.

“Due to the increased abdominal weight, take your time with walking as your balance might be affected and cause a fall.”.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While it is true that an increased weight in the abdomen can lead to discomfort when lying down, simply having extra pillows in bed may not be sufficient to address the issue. Ascites, or the accumulation of fluid in the peritoneal cavity, can cause significant discomfort and even

pain. It can also lead to respiratory issues as the fluid puts pressure on the diaphragm, making breathing difficult. Therefore, while extra pillows may help to some extent by allowing the patient to find a more comfortable position, they are not a comprehensive solution.
Choice B rationale
Advising the patient not to wear undergarments because they will not fit due to the increased weight in the abdomen is not a medically sound advice. While it is true that ascites can cause distension of the abdomen, the focus should be on treating the underlying condition and managing the symptoms, rather than on the fit of the patient’s clothing. Moreover, the choice of clothing is a personal decision and may have psychological implications for the patient.
Choice C rationale
The statement that the increased weight in the abdomen means that the patient can no longer exercise due to the strain on the heart is not entirely accurate. While it is true that ascites can put additional strain on the heart and other organs, it does not necessarily mean that all forms of exercise are contraindicated. In fact, gentle forms of exercise may be beneficial for overall health and well-being. However, any exercise regimen should be discussed with and approved by a healthcare provider.
Choice D rationale
This is the correct choice. Due to the increased abdominal weight from ascites, the patient’s balance might indeed be affected, increasing the risk of falls. Therefore, advising the patient to take their time with walking is a valid precaution. Fall prevention is a key aspect of care for patients with ascites due to end-stage liver disease.

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Correct Answer is C

Explanation

Choice A rationale
Free T4 levels are typically low in primary hypothyroidism, not elevated.

Choice B rationale
Serum T3 levels are also typically low in primary hypothyroidism.
Choice C rationale
In primary hypothyroidism, the thyroid gland is not producing enough thyroid hormone, leading to an elevated TSH level as the pituitary gland tries to stimulate more hormone production.
Choice D rationale
Serum calcium levels are not directly affected by primary hypothyroidism.

A. Providing information B. Summarizing C. Clarification D. Confrontation

Correct Answer is C

Explanation

Choice A rationale
Providing information is a communication technique where the nurse gives the patient factual and relevant information. In this scenario, the nurse is not providing information but rather seeking to understand the patient’s feelings.
Choice B rationale
Summarizing is a communication technique where the nurse reviews the main points of the conversation to ensure understanding. In this scenario, the nurse is not summarizing the conversation but rather seeking to understand the patient’s feelings.

Choice C rationale
Clarification is a communication technique where the nurse seeks to understand the patient’s message by asking for more information or for elaboration on a point. In this scenario, the nurse is using clarification by restating the patient’s concern in a different way to confirm their understanding.
Choice D rationale
Confrontation is a communication technique where the nurse addresses observed discrepancies or conflicts in the patient’s behavior or communication. In this scenario, the nurse is not confronting the patient but rather seeking to understand their feelings.

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A nurse is caring for an elderly patient with significant ascites due to end-stage liver disease. Which of the following precautions should the nurse include in the patient’s care plan?

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