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
Donating blood after completing the medication regimen is not typically recommended for patients with hepatitis B. Hepatitis B is a bloodborne virus, and individuals with the virus should not donate blood.
Choice B rationale
Resting frequently throughout the day is a key part of self-management for patients with hepatitis B. Rest can help the body recover and fight off the virus.
Choice C rationale
Taking acetaminophen every 4 hours for discomfort is not typically recommended for patients with hepatitis B. Overuse of acetaminophen can lead to liver damage, which can be particularly harmful for individuals with liver diseases like hepatitis B56.
Choice D rationale
Consuming a high-protein diet is not typically recommended for patients with hepatitis B. A balanced diet is important for overall health, but there are no specific dietary recommendations for hepatitis B56.
Correct Answer is D
Explanation
Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale
Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.
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