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
Explanation
Choice A rationale
Anemia due to excessive blood loss during surgery can lead to a variety of symptoms. One of the most common symptoms is fatigue. This is because anemia results in a decrease in the amount of oxygen that can be delivered to the body’s tissues, leading to a lack of energy and feelings of exhaustion. Therefore, a nurse should expect to find fatigue in a postoperative client who has anemia due to excessive blood loss during surgery.
Choice B rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with anemia. Instead, anemia can actually lead to tachycardia, or a faster than normal heart rate, as the body tries to compensate for the decreased oxygen carrying capacity of the blood.
Choice C rationale
Hypertension, or high blood pressure, is not a typical finding in patients with anemia. In fact, in severe cases, anemia can lead to hypotension, or low blood pressure, due to a decrease in the blood’s ability to carry oxygen.
Choice D rationale
Diarrhea is not a common symptom of anemia. Anemia due to excessive blood loss during surgery is more likely to result in symptoms related to a lack of oxygen in the body’s tissues, such as fatigue, weakness, and shortness of breath.
Correct Answer is A
Explanation
Choice A rationale
Hip arthroplasty, or hip replacement surgery, is a procedure that has been associated with a higher risk of deep vein thrombosis (DVT)8910. This is due to factors such as the length of the
procedure, the immobility of the patient during and after the procedure, and the location of the surgery in the lower extremities.
Choice B rationale
Cataract extraction is not typically associated with a high risk of DVT8910. This is a relatively quick and minimally invasive procedure, and it does not involve the lower extremities, which are the most common sites for DVT8910.
Choice C rationale
Myringotomy, a procedure to drain fluid from the middle ear, is not associated with a high risk of DVT8910. This is a quick and minimally invasive procedure, and it does not involve the lower extremities.
Choice D rationale
Laparoscopic appendectomy, while a surgical procedure, is not typically associated with a high risk of DVT8910. The risk of DVT is generally lower with laparoscopic procedures compared to open surgeries.
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