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 D
Explanation
Choice A rationale
Limiting fluid intake to 1 liter per day is not recommended for patients who have experienced an acute gout attack. Adequate hydration is important for all individuals, especially those with gout, as it can help to prevent the formation of uric acid crystals.
Choice B rationale
Taking one aspirin every day is not typically recommended for gout patients. Aspirin can actually increase uric acid levels in the blood and potentially trigger a gout attack.
Choice C rationale
Adhering to a high-purine diet is not recommended for gout patients. Foods high in purines can increase uric acid levels in the blood, potentially triggering a gout attack.
Choice D rationale
Restricting alcohol consumption is a key part of managing gout. Alcohol, especially beer, can increase uric acid levels in the blood and trigger gout attacks.
Correct Answer is D
Explanation
Choice A rationale
The situation component of the SBAR tool typically involves a brief description of the current problem or concern. Stating that a bowel resection was performed does not describe a current problem or concern.
Choice B rationale
The recommendation component of the SBAR tool involves suggesting a course of action or asking for assistance. Stating that a bowel resection was performed does not suggest a course of action or ask for assistance.
Choice C rationale
The assessment component of the SBAR tool involves sharing your analysis or opinion about the situation. Stating that a bowel resection was performed does not share an analysis or opinion.
Choice D rationale
This is the correct answer. The background component of the SBAR tool involves providing context or background information relevant to the situation. Stating that a bowel resection was
performed provides relevant background information about the patient’s recent medical history. DysphagiaDysphagia Explore
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