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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Taking ibuprofen for eye discomfort after cataract surgery is not typically recommended. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding, which can be problematic after eye surgery.
Choice B rationale
Wearing dark glasses while outdoors is often recommended after cataract surgery. This is because the eyes can be sensitive to light after the procedure. Dark glasses can help to protect the eyes from bright light and reduce discomfort.
Choice C rationale
Itching in the operative eye is not typically a sign of a serious problem after cataract surgery. Some itching can be normal as the eye heals. However, severe pain, vision loss, or heavy discharge should be reported to the provider immediately.
Choice D rationale
Creamy white drainage is not an indication of infection. In fact, it could be a sign of a more serious problem, such as an eye infection. Any changes in vision, pain, redness, or discharge should be reported to the healthcare provider.
Correct Answer is C
Explanation
Choice A rationale
While heart failure can lead to fluid volume imbalances, a BNP level of 600 pg/mL alone does not indicate a risk for fluid volume deficit.
Choice B rationale
Being NPO since midnight for an endoscopy could potentially lead to fluid volume deficit, but it’s not the most likely choice. Typically, patients are adequately hydrated before and after the procedure.
Choice C rationale
A patient with gastroenteritis and a fever is at high risk for fluid volume deficit. Gastroenteritis can cause significant fluid loss through vomiting and diarrhea, and fever increases insensible water loss.
Choice D rationale
While patients with end-stage renal failure can have fluid volume imbalances, they are more likely to experience fluid volume excess, especially if they are due for dialysis.
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