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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
Hyperthermia and severe tachycardia are not typical symptoms of damage to the parathyroid glands.
Choice B rationale
Hypercalcemia and shortness of breath are not typical symptoms of damage to the parathyroid glands.
Choice C rationale
Laryngospasms and tingling in the hands and feet can be symptoms of hypoparathyroidism, a condition that can occur if the parathyroid glands are damaged. Hypoparathyroidism can lead to low levels of calcium in the blood, which can cause these symptoms.
Choice D rationale
Hypophosphatemia, hypertension, vomiting, and chest pain are not typical symptoms of damage to the parathyroid glands.

A. Increase the client’s sodium intake. B. Increase the client’s saturated fat intake. C. Decrease the client’s fluid intake. D. Decrease the client’s carbohydrate intake.

Correct Answer is C

Explanation

Choice A rationale
Increasing sodium intake is not recommended for a client with cirrhosis and ascites. Sodium can cause fluid retention, which can worsen ascites.
Choice B rationale
Increasing saturated fat intake is not recommended for a client with cirrhosis and ascites. A balanced diet with adequate protein and carbohydrates is recommended.
Choice C rationale
Decreasing fluid intake can be a part of the management plan for a client with cirrhosis and ascites. This can help manage fluid balance and prevent further accumulation of fluid in the abdomen.
Choice D rationale
Decreasing carbohydrate intake is not typically recommended for a client with cirrhosis and ascites. Carbohydrates provide a source of energy that is necessary for the body’s functions.

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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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