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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.
Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.
Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.
Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.
Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale
Proteinuria, or the presence of an abnormal amount of protein in the urine, is a hallmark sign of glomerulonephritis. It occurs due to the increased permeability of the glomerular filtration barrier.
Choice B rationale
Hypertension is often associated with glomerulonephritis. The damage to the glomeruli can lead to salt and water retention, contributing to high blood pressure.
Choice C rationale
Periorbital edema, which is swelling around the eyes, is a common early symptom of glomerulonephritis. It is caused by fluid retention and leakage into the tissue.
Choice D rationale
Hypotension is not typically associated with glomerulonephritis. In fact, hypertension is more common due to the reasons mentioned above.
Choice E rationale
Hematuria, or blood in the urine, is another common finding in glomerulonephritis. It results from the inflammation and damage to the glomeruli, allowing red blood cells to leak into the urine.
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