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 D
Explanation
Choice A rationale
Palpating over the maxillary sinuses is not typically associated with oral cancer assessment. This action is more relevant to sinus issues and does not provide information about oral cancer.
Choice B rationale
Asking about a productive cough can be relevant in assessing respiratory conditions but is not a direct method for evaluating oral cancer. Oral cancer symptoms are more localized to the mouth area.
Choice C rationale
Observing for purulent nasal drainage is not a standard action in assessing for oral cancer. Nasal drainage would be more indicative of sinus or respiratory issues, not oral pathology.
Choice D rationale
Checking the mouth for leukoplakia is a key action when assessing for oral cancer. Leukoplakia presents as thickened, white patches inside the mouth and can be precancerous, making it a critical observation in potential oral cancer cases.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A rationale
Hypertension is not a typical manifestation of pyelonephritis. While it can be present due to other underlying conditions, it is not directly related to pyelonephritis.
Choice B rationale
Frequency, or the need to urinate more often, is a common symptom of pyelonephritis as the infection can irritate the bladder and urinary tract.
Choice C rationale
Flank pain is a classic symptom of pyelonephritis. It is usually located on the side of the affected kidney and can be quite severe.
Choice D rationale
Neck pain is not associated with pyelonephritis. It is more likely related to musculoskeletal issues or other non-urinary tract conditions.
Choice E rationale
Costovertebral tenderness, which is tenderness felt on tapping the back where the ribs meet the spine, is indicative of kidney infection and is expected in pyelonephritis.
Choice F rationale
Urgency, or a sudden, strong need to urinate, is another symptom of pyelonephritis due to inflammation and irritation in the urinary system.
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