A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
Restrict the client's sodium intake to 3 g per day.
Position the client supine with legs elevated.
Measure the client's abdominal girth daily.
Keep the client's daily protein intake below 0.8 g/kg.
The Correct Answer is C
A. Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.
The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.
Correct Answer is C
Explanation
Perpetrators of child abuse often exhibit rigid expectations of behavior, demanding strict adherence to rules and may have unrealistic or age-inappropriate expectations for their children. This can lead to increased stress and frustration, which may manifest in abusive behaviors.
Laissez-faire leadership style: A laissez-faire leadership style refers to a hands-off or
non-directive approach, where individuals allow others to make decisions and take control. While this leadership style may have its own implications, it is not specifically associated with child abuse.
Self-blame for financial problems: Self-blame for financial problems may indicate feelings of guilt or personal responsibility for economic difficulties. While financial stress can contribute to increased risk of child abuse, self-blame alone is not a characteristic specific to perpetrators of child abuse.
High self-esteem: High self-esteem refers to a positive self-regard and belief in one's abilities and worth. While low self-esteem can contribute to various psychological issues, including potential difficulties in parenting, high self-esteem is not a characteristic specifically associated with perpetrators of child abuse.
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