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 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.
Correct Answer is D
Explanation
Choice A rationale
An increase in intraocular pressure is not a cause of diabetic retinopathy. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to high blood sugar levels.
Choice B rationale
While regular eye exams are important for patients with diabetes mellitus, having an eye exam every 2 years may not be sufficient for detecting and managing diabetic retinopathy. More frequent eye exams may be recommended depending on the patient’s condition.
Choice C rationale
Clouding of the lens is not a manifestation of diabetic retinopathy. This is a symptom of cataracts, not diabetic retinopathy. Diabetic retinopathy affects the blood vessels in the retina, not the lens of the eye.
Choice D rationale
Seeing spots, also known as floaters, is a common symptom of diabetic retinopathy. This occurs when blood and other fluids leak into the vitreous, the clear, jelly-like substance that fills the inside of the eye.
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