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
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Correct Answer is B
Explanation
Choice A rationale
While chronic exposure to UV rays can cause skin dryness, it does not decrease the water content of the skin20. Skin dryness is more of a symptom rather than a risk factor for skin cancer20.
Choice B rationale
Chronic exposure to UV rays can cause an error in the skin’s genetic code20. This can lead to the development of skin cancer, as the damaged DNA can lead to uncontrolled cell growth20.
Choice C rationale
Increased blood flow to the skin is not a direct result of chronic exposure to UV rays20. While UV rays can cause skin redness and inflammation, these are not directly linked to an increased risk of skin cancer20.
Choice D rationale
Chronic exposure to UV rays does not cause degeneration of elastic fibers in skin tissue20. While UV rays can cause skin aging and wrinkles, these are not direct risk factors for skin cancer20. Diabetic retinopathyDiabetic retinopathy Explore
Correct Answer is C
Explanation
Choice A rationale
Periorbital edema is not typically associated with the progression of systemic scleroderma.
Choice B rationale
Excessive salivation is not typically associated with the progression of systemic scleroderma.
Choice C rationale
Finger contractures can be expected in a client diagnosed with systemic scleroderma. As the disease progresses, it can cause tightening and hardening of the skin, which can lead to contractures.
Choice D rationale
Thinning of the skin is not typically associated with the progression of systemic scleroderma. In fact, the disease often causes the skin to thicken.
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