A nurse is planning care for a client who has cirrhosis and ascites.
Which of the following interventions should the nurse include in the plan of care?

Choice A rationale
While acetaminophen can be used to relieve discomfort, it should be used with caution in patients with liver disease like cirrhosis, as it can potentially cause further liver damage.

Choice B rationale
Patients with cirrhosis, especially those with ascites, are often advised to limit their sodium intake. High-sodium foods can contribute to fluid retention and worsen ascites. Therefore, avoiding high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners is a key part of managing cirrhosis.
Choice C rationale
While maintaining adequate nutrition is important in cirrhosis, eating three large meals per day is not typically recommended. Instead, smaller, more frequent meals are often suggested.
Choice D rationale
While physical activity is generally beneficial, patients with cirrhosis and particularly those with complications such as ascites or encephalopathy may need to modify their activity levels based on their symptoms and overall health.

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.