A nurse is caring for an elderly patient with significant ascites due to end-stage liver disease. Which of the following precautions should the nurse include in the patient’s care plan?
“An increased weight in the abdomen can lead to problems with getting comfortable when lying down, therefore, have extra pillows in bed.”.
“Due to the increased weight in the abdomen, it is advised that you do not wear undergarments as they will not fit.”.
“The increased weight in your abdomen will mean that you can no longer exercise due to the strain on your heart.”.
“Due to the increased abdominal weight, take your time with walking as your balance might be affected and cause a fall.”.
The Correct Answer is D
Choice A rationale
While it is true that an increased weight in the abdomen can lead to discomfort when lying down, simply having extra pillows in bed may not be sufficient to address the issue. Ascites, or the accumulation of fluid in the peritoneal cavity, can cause significant discomfort and even
pain. It can also lead to respiratory issues as the fluid puts pressure on the diaphragm, making breathing difficult. Therefore, while extra pillows may help to some extent by allowing the patient to find a more comfortable position, they are not a comprehensive solution.
Choice B rationale
Advising the patient not to wear undergarments because they will not fit due to the increased weight in the abdomen is not a medically sound advice. While it is true that ascites can cause distension of the abdomen, the focus should be on treating the underlying condition and managing the symptoms, rather than on the fit of the patient’s clothing. Moreover, the choice of clothing is a personal decision and may have psychological implications for the patient.
Choice C rationale
The statement that the increased weight in the abdomen means that the patient can no longer exercise due to the strain on the heart is not entirely accurate. While it is true that ascites can put additional strain on the heart and other organs, it does not necessarily mean that all forms of exercise are contraindicated. In fact, gentle forms of exercise may be beneficial for overall health and well-being. However, any exercise regimen should be discussed with and approved by a healthcare provider.
Choice D rationale
This is the correct choice. Due to the increased abdominal weight from ascites, the patient’s balance might indeed be affected, increasing the risk of falls. Therefore, advising the patient to take their time with walking is a valid precaution. Fall prevention is a key aspect of care for patients with ascites due to end-stage liver disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Hepatitis A is a highly contagious virus that spreads through person-to-person contact or consuming contaminated food or drink. The virus can contaminate food during growing, harvesting, processing, handling, and even after cooking. Therefore, avoiding serving raw foods can help prevent the spread of the virus.
Choice B rationale
Hepatitis A is not typically spread through sexual intercourse. It is primarily spread through the fecal-oral route, either by person-to-person contact or consumption of contaminated food or water. Therefore, wearing barrier protection during vaginal intercourse is not a primary prevention strategy for Hepatitis A.
Choice C rationale
While it’s possible to contract Hepatitis A from food prepared at any location, including fast food restaurants, the risk is not specifically associated with these establishments. The key is whether the food is contaminated with the virus, which can occur in any setting if food is handled by someone infected with Hepatitis A who doesn’t properly wash their hands after using the toilet.
Choice D rationale
Practicing effective hand hygiene, including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food, is a primary prevention strategy for Hepatitis A1. The virus is spread in part by the fecal-oral route, so good hand hygiene can help prevent ingestion of the virus.
Correct Answer is D
Explanation
Choice A rationale
While nutrition is important for recovery, consuming 35% of meals for 12 hours is not an immediate concern. The patient’s nutritional status can be addressed after more urgent issues are resolved.
Choice B rationale
Bedrest for 3 days post-surgery is not uncommon. While prolonged bedrest can lead to complications such as deep vein thrombosis, it is not the most immediate concern in this scenario.
Choice C rationale
A last bowel movement 2 days ago is not necessarily a concern unless the patient is experiencing discomfort or other symptoms of constipation. This can be addressed after more urgent issues are resolved.
Choice D rationale
This is the correct answer. Pain in the lower extremities following surgery could indicate a serious condition such as a blood clot. It is important to address this first to rule out any serious complications.
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