A nurse is caring for an older adult client who has significant issues with ascites related to end-stage liver disease. Which of the following precautions is most important for the nurse to include in the teaching?
"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 may not fit properly."
"Due to the increased abdominal weight, take your time with walking as your balance might be affected and could cause a fall."
"The increased weight in your abdomen will mean that you can no longer exercise due to the strain on your heart."
The Correct Answer is C
Choice A rationale
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
Choice B rationale
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
Choice C rationale
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
Choice D rationale
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A history of high blood pressure is a risk factor for chronic kidney disease but not specifically for acute glomerulonephritis. Acute glomerulonephritis is more commonly associated with infections.
Choice B rationale
A recent sore throat and fever, especially if caused by a streptococcal infection, can lead to post-streptococcal glomerulonephritis. This is a well-documented cause of acute glomerulonephritis, making it the correct answer.
Choice C rationale
While bladder infections can lead to urinary tract infections, they are not typically associated with acute glomerulonephritis. This condition is more commonly related to infections that can cause a systemic immune response.
Choice D rationale
A history of kidney stones is associated with chronic kidney issues and can lead to infections, but it is not a direct cause of acute glomerulonephritis. This condition is usually caused by an immune response to an infection elsewhere in the body.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Hypertension is a modifiable risk factor for atherosclerosis. Managing blood pressure through lifestyle changes and medication can reduce the risk of developing atherosclerosis.
Choice B rationale
Hypercholesterolemia, or high cholesterol, is another modifiable risk factor. Dietary adjustments, physical activity, and medications can help manage cholesterol levels.
Choice C rationale
Genetic predisposition is not a modifiable risk factor. It is an inherent risk that cannot be changed, but awareness can prompt early monitoring and intervention.
Choice D rationale
Obesity is a modifiable risk factor for atherosclerosis. Weight loss through diet and exercise can significantly reduce the risk.
Choice E rationale
Smoking is a significant modifiable risk factor for atherosclerosis. Quitting smoking can greatly reduce the risk of developing this condition.
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