A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?
(Select all that apply.)
Provide diet low in phosphorus.
Note signs of swelling and edema.
Increase oral fluid intake to 1,500 mL daily.
Monitor abdominal girth.
Report serum albumin and globulin levels.
Correct Answer : B,D,E
Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.
Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Which medication works best for you? This is not the most important question, as it does not address the current status or risk of the client. The medication history is a part of the assessment, but it does not help identify the content or impact of the hallucinations.
Choice B: When do you hear voices? This is not the most important question, as it does not address the current status or risk of the client. The frequency and timing of the hallucinations are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice C: How do you cope with the voices? This is not the most important question, as it does not address the current status or risk of the client. The coping strategies are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice D: What are the voices saying? This is the most important question, as it addresses the current status and risk of the client. The content and impact of the hallucinations are a part of the assessment, as they can help identify if the client is experiencing command hallucinations, which may instruct them to harm themselves or others.
Correct Answer is ["A","B"]
Explanation
Choice A: Avoid salt substitutes. This client needs additional education, as salt substitutes may contain potassium, which can increase the risk of hyperkalemia in clients with coronary artery disease. The nurse should teach the client to use herbs, spices, or lemon juice to flavor food instead of salt or salt substitutes.
Choice B: Consume canned vegetables. This client needs additional education, as canned vegetables may contain sodium, which can increase the blood pressure and worsen coronary artery disease. The nurse should teach the client to choose fresh or frozen vegetables instead of canned ones.
Choice C: Include oatmeal for breakfast. This client does not need additional education, as oatmeal is a good source of soluble fiber, which can lower cholesterol and reduce the risk of atherosclerosis. The nurse should praise the client for this healthy choice.
Choice D: Identify foods with saturated fats. This client does not need additional education, as identifying foods with saturated fats is an important step to avoid them. Saturated fats can raise cholesterol and increase the risk of coronary artery disease. The nurse should teach the client to limit saturated fats to less than 10% of total calories per day.
Choice E: Walk 30 minutes per day. This client does not need additional education, as walking 30 minutes per day is a recommended physical activity for clients with coronary artery disease. Physical activity can improve blood circulation, lower blood pressure, and reduce stress. The nurse should encourage the client to walk at a moderate pace and consult with the healthcare provider before starting any exercise program.
Choice F: Keep a food diary. This client does not need additional education, as keeping a food diary is a helpful tool to monitor dietary intake and identify areas for improvement. The nurse should teach the client to record the type, amount, and time of food consumed, as well as any symptoms or feelings associated with eating.
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