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
No explanation
Correct Answer is C
Explanation
Thyrotoxicosis refers to a state of excess thyroid hormone in the body, which can occur as a result of excessive levothyroxine dosage or other causes. Nervousness is a common symptom of thyrotoxicosis, characterized by an excessive or uncontrollable feeling of anxiety or restlessness. It is important for the client to report this symptom to the healthcare provider because it may indicate an imbalance in thyroid hormone levels and may require adjustment of the medication dosage.
Polyuria, which refers to increased urination, is not a specific symptom of thyrotoxicosis. It can occur due to various factors unrelated to thyroid function.
Pruritus, or itching, is not a common symptom of thyrotoxicosis. It may be associated with other conditions or causes.
Cough is not typically associated with thyrotoxicosis. It is more commonly related to respiratory or pulmonary conditions rather than thyroid dysfunction.
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