A nurse is assessing an elderly patient who has just been admitted to the medical-surgical unit with significant abdominal ascites.
The patient is alert and oriented, walks independently at home, and usually uses a cane but forgot to bring it to the hospital.Which measures should the nurse prioritize?
Implementing a bleeding precaution protocol
Implementing a skin safety protocol
Implementing a sodium restriction diet
Implementing a fall risk protocol
The Correct Answer is D
Choice A rationale
While bleeding precautions are important in certain conditions, they may not be the priority for a patient with significant abdominal ascites. Ascites, the accumulation of fluid in the peritoneal cavity, is often caused by liver disease such as cirrhosis.
Choice B rationale
Skin safety protocols are important for all patients, but they may not be the priority in this case. Ascites can cause discomfort and other complications, but it does not directly cause skin problems.
Choice C rationale
A sodium restriction diet can be beneficial for patients with ascites, as it can help reduce fluid accumulation. However, this measure may not be the priority in this case.
Choice D rationale
Implementing a fall risk protocol should be prioritized. The patient’s significant abdominal ascites could affect their balance and mobility, increasing their risk of falls. Furthermore, the patient usually uses a cane for support but forgot to bring it to the hospital, further increasing their fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A stool guaiac test is a simple check to find blood in your stool. It involves smearing a tiny amount of your stool on a special card, which is then tested for hidden blood. This test helps detect problems like bleeding ulcers or colon cancer in an early stage when they might not show other symptoms. The stool guaiac test looks for hidden (occult) blood in a stool sample. It can find blood even if you cannot see it yourself. It is a common type of fecal occult blood test (FOBT). Guaiac is a substance from a plant that is used to coat the FOBT test cards to make them able to detect blood.
Choice B rationale
Steatorrhea refers to the presence of excess fat in the stool. While this can be a symptom of various digestive disorders, it is not what a stool guaiac test is designed to detect. The primary purpose of a stool guaiac test is to identify hidden blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.
Choice C rationale
While bacteria can be present in the stool and certain tests are designed to detect them, a stool guaiac test is not one of these. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool. The presence of blood can indicate a variety of conditions, including gastrointestinal bleeding or colon cancer.
Choice D rationale
Yeast can be present in the stool, and certain tests can detect it. However, a stool guaiac test is not designed to detect yeast. The primary purpose of a stool guaiac test is to identify hidden
blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.
Correct Answer is C
Explanation
Choice A rationale
While performing self-examinations for breast cancer can help in early detection of the disease, it does not provide information about a person’s genetic risk for developing breast cancer.
Choice B rationale
Having a suspicious mammogram could indicate the presence of breast cancer or other abnormalities, but it does not provide information about a person’s genetic risk for developing the disease.
Choice C rationale
Being aware of one’s BRCA (breast cancer gene) status is directly related to understanding their genetic risk for breast cancer. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer.
Choice D rationale
Noticing dimpling during a breast self-exam could be a sign of breast cancer, but it does not provide information about a person’s genetic risk for developing the disease.
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