A nurse is caring for an older adult client who has significant issues with ascites related to end-stage liver disease. Which of the following precautions is most important for the nurse to include in the teaching?
"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 may not fit properly."
"Due to the increased abdominal weight, take your time with walking as your balance might be affected and could cause a fall."
"The increased weight in your abdomen will mean that you can no longer exercise due to the strain on your heart."
The Correct Answer is C
Choice A rationale
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
Choice B rationale
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
Choice C rationale
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
Choice D rationale
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Jaundice of the sclera is indicative of hyperbilirubinemia, which can occur in various liver diseases but is not specifically associated with Grey Turner's sign or pancreatitis.
Choice B rationale
Bluish discoloration of the periumbilical area, known as Cullen's sign, is another indicator of severe pancreatitis but is distinct from Grey Turner's sign, which specifically refers to the flank area.
Choice C rationale
Left abdominal pain that occurs with movement may be a symptom experienced by patients with pancreatitis, but it is not referred to as Grey Turner's sign, which is a physical finding rather than a symptom.
Choice D rationale
Grey Turner's sign is characterized by bluish discoloration of the flank area. It is a sign of retroperitoneal hemorrhage, which can occur in severe cases of pancreatitis due to the spread of pancreatic enzymes to surrounding tissues, leading to localized bleeding.
Correct Answer is C
Explanation
Choice A rationale
Congestive heart failure is not directly associated with an increased risk of developing acute pancreatitis. While it can contribute to overall health deterioration, it does not cause the condition.
Choice B rationale
Emphysema primarily affects the lungs and does not increase the risk of acute pancreatitis. It is a chronic obstructive pulmonary disease and is unrelated to pancreatic function.
Choice C rationale
Alcohol abuse is a well-known risk factor for acute pancreatitis. It can lead to repeated episodes of inflammation in the pancreas, which can eventually become chronic and lead to acute pancreatitis.
Choice D rationale
Diabetes mellitus is a result of chronic pancreatitis or can be a comorbidity, but it is not a direct cause of acute pancreatitis. However, it can be associated with complications related to the pancreas.
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