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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.
Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.
Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.
Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.
Correct Answer is B
Explanation
Choice A reason : Benzodiazepines are not typically used for the long-term treatment of obsessive-compulsive disorder due to the risk of dependence and because other medications, such as SSRIs, are more effective for long-term management⁵.
Choice B reason : Benzodiazepines are effective for the short-term management of panic attacks due to their rapid onset of action, which can quickly alleviate acute symptoms of anxiety and panic⁵⁹.
Choice C reason : Long-term treatment of agoraphobia generally involves psychotherapy and SSRIs or SNRIs rather than benzodiazepines, which can lead to dependence and are not recommended for long-term use⁵.
Choice D reason : Benzodiazepines are not the first-line treatment for depression and are generally not used for this purpose. Antidepressants and psychotherapy are the standard treatments for depression⁵.
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