The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Provide only distilled water.

Document abdominal girth.

Offer a high protein diet.

Use a cushion when sitting.

Answer and Explanation

The Correct Answer is B

A.   Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B.   Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D.   Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

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Correct Answer is B

Explanation

A. Gained 10 lb (4.5 kg) within one month. Weight gain is not typically associated with the onset of type 1 diabetes. In fact, weight loss is more common due to the body's inability to use glucose properly.
B. Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.
C. Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.
D. Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.

A. Provide counseling that most contraceptives protect against infection. B. Remain non-judgmental and assure the client of confidentiality. C. Inform the client that complications will not result from reinfection. D. Clarify that all STIs are transmitted through sexual intercourse.

Correct Answer is B

Explanation

A. Providing counseling about contraceptives may not address the immediate concern of managing genital herpes or the risks associated with multiple sexual partners.
B. Remaining non-judgmental and assuring the client of confidentiality is crucial to establishing trust and ensuring open communication. This approach encourages the client to share accurate information about their sexual history and current concerns, which is essential for effective STI management and prevention.
C. Informing the client that complications will not result from reinfection is inaccurate and may minimize the seriousness of the STI. Genital herpes can cause recurrent outbreaks and potentially lead to complications such as neonatal herpes if transmitted to a newborn during childbirth.

D. Clarifying that all STIs are transmitted through sexual intercourse is true but does not address the client's specific situation or provide guidance on managing genital herpes and reducing the risk of transmission.

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The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Nursing Test Bank

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