A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Decrease the client's carbohydrate intake.

Increase the client's saturated fat intake.

Decrease the client's fluid intake.

Increase the client's sodium intake.

Answer and Explanation

The Correct Answer is C

Choice A reason : Decreasing the client's carbohydrate intake is not typically a priority intervention for cirrhosis and ascites. While managing overall nutrition is important, carbohydrates are a necessary component of a balanced diet and provide essential energy¹.

Choice B reason : Increasing the client's saturated fat intake is not recommended in cirrhosis and ascites. Saturated fats can contribute to fatty liver disease and worsen liver function. A diet low in saturated fats and high in omega-3 fatty acids is generally advised¹.

Choice C reason : Decreasing the client's fluid intake is a key intervention for managing ascites in cirrhosis. Ascites is the accumulation of fluid in the peritoneal cavity, and reducing fluid intake can help manage this condition. The goal is to prevent further fluid accumulation and reduce the risk of complications such as spontaneous bacterial peritonitis¹².

Choice D reason : Increasing the client's sodium intake is not advised for cirrhosis and ascites. Sodium can cause the body to retain water, exacerbating fluid accumulation in the abdomen. A low-sodium diet is typically recommended to help control ascites¹.

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Correct Answer is D

Explanation

Choice A reason : Implementing seizure precautions is necessary for a child with bacterial meningitis due to the increased risk of seizures associated with the condition.

Choice B reason : Placing the client in a semi-Fowler's position can help reduce intracranial pressure and facilitate breathing, which is beneficial for a child with meningitis.

Choice C reason : Admitting the client to a private room is important to prevent the spread of infection and provide a quiet environment to reduce the risk of seizures and other complications.

Choice D reason : Measuring head circumference every shift is not typically necessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants whose skull bones have not yet fused.

A. Assure the client that their end-of-life wishes are followed right away. B. Check the medical record for a DNR order. C. Ask the client if they have a healthcare proxy who can speak for them if needed. D. Verify a signed copy of the advance directives in the medical record.

Correct Answer is B

Explanation

Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².

Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².

Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².

Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².

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A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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