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
Explanation
Choice A rationale
The red blood cell (RBC) count is not typically affected by hemodialysis. Hemodialysis is a process that primarily targets the removal of waste products and excess fluid from the blood, not red blood cells.
Choice B rationale
Potassium levels are often elevated in clients with renal failure due to the kidneys' inability to excrete potassium. Hemodialysis helps to remove excess potassium from the bloodstream, thereby decreasing its levels.
Choice C rationale
Calcium levels can be affected by hemodialysis; however, they are more often managed with medication and diet rather than being directly targeted by the dialysis process itself.
Choice D rationale
Protein levels should not decrease significantly as a result of hemodialysis. The dialysis membrane is designed to allow small waste products to pass through while retaining larger molecules like proteins.
Correct Answer is B
Explanation
Choice A rationale
Potassium levels are not directly affected by lactulose. While cirrhosis can lead to imbalances in electrolytes, including potassium, lactulose is not used to manage potassium levels in the bloodstream.
Choice B rationale
Ammonia is produced by the breakdown of proteins in the intestines and is normally processed by the liver. In cirrhosis, the liver's ability to convert ammonia to urea is impaired, leading to increased levels in the blood. Lactulose helps reduce blood ammonia levels by converting it into ammonium, which is then excreted.
Choice C rationale
Bicarbonate levels are related to the body's pH balance and are not the target of lactulose treatment. Cirrhosis does not typically result in bicarbonate imbalances that would be treated with lactulose.
Choice D rationale
Glucose levels are managed by insulin and other metabolic processes, not lactulose. While cirrhosis can affect overall metabolism, lactulose does not have a direct effect on blood glucose levels.
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