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A nurse is evaluating a client admitted to the emergency unit.

Exhibits
Which nursing interventions are appropriate for managing a patient with cirrhosis experiencing fluid volume excess?

A.

Advise strict bed rest

B.

Encourage high-sodium diet

C.

Administer diuretics as prescribed

D.

Monitor abdominal girth daily

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Rationale

  • Advise strict bed rest → Contraindicated
     Strict bed rest is not necessary unless the patient is severely compromised; mobility is encouraged to prevent complications.
     
  • Encourage high-sodium diet → Contraindicated
     A low-sodium diet is essential to reduce fluid retention and ascites; high sodium worsens edema.
     
  • Administer diuretics as prescribed → Anticipated
     Diuretics (e.g., spironolactone, furosemide) help reduce ascites and edema.
     
  • Monitor abdominal girth daily → Anticipated
     Helps track fluid accumulation and assess effectiveness of interventions.


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Related Questions

Correct Answer is B

Explanation

Rationale:
A. Obtaining a dietary history is important but not the priority in an acute exacerbation.
B. Reviewing electrolyte values is the first action. Clients with acute ulcerative colitis are at risk for fluid and electrolyte imbalances due to diarrhea, making this a priority assessment to prevent complications.
C. Investigating emotional concerns is important for holistic care but is secondary to addressing physiologic needs.
D. Checking perianal skin integrity is necessary but comes after assessing critical physiologic risks like electrolyte imbalances.

Correct Answer is B

Explanation

Rationale:
A. Clients with hepatitis often experience anorexia and nausea. Small, frequent meals are better tolerated than three large meals.
B. Carbohydrates are the primary source of calories in clients with hepatitis. They help spare protein and allow the liver to rest and heal. This is the recommended dietary intervention.
C. Protein should be limited in clients with severe hepatitis, especially if liver function is impaired, because excess protein can worsen encephalopathy.
D. Acetaminophen is hepatotoxic and should be avoided in clients with hepatitis due to the risk of further liver damage.

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