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?
Decrease the client's carbohydrate intake.
Increase the client's saturated fat intake.
Decrease the client's fluid intake.
Increase the client's sodium intake.
The Correct Answer is C
Choice A reason : Decreasing the client's carbohydrate intake is not typically a priority intervention for cirrhosis and ascites. While managing overall nutrition is important, carbohydrates are a necessary component of a balanced diet and provide essential energy¹.
Choice B reason : Increasing the client's saturated fat intake is not recommended in cirrhosis and ascites. Saturated fats can contribute to fatty liver disease and worsen liver function. A diet low in saturated fats and high in omega-3 fatty acids is generally advised¹.
Choice C reason : Decreasing the client's fluid intake is a key intervention for managing ascites in cirrhosis. Ascites is the accumulation of fluid in the peritoneal cavity, and reducing fluid intake can help manage this condition. The goal is to prevent further fluid accumulation and reduce the risk of complications such as spontaneous bacterial peritonitis¹².
Choice D reason : Increasing the client's sodium intake is not advised for cirrhosis and ascites. Sodium can cause the body to retain water, exacerbating fluid accumulation in the abdomen. A low-sodium diet is typically recommended to help control ascites¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.
Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.
Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.
Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.
Correct Answer is A
Explanation
Choice A reason : A sore throat is a common side effect of radiation therapy to the neck area, particularly for cancer of the larynx. The radiation can cause inflammation and irritation of the throat and laryngeal tissues, leading to pain and discomfort when swallowing¹⁵. This side effect can be managed with pain relief medications and dietary adjustments to include softer foods and liquids.
Choice B reason : Dry mouth, or xerostomia, occurs when radiation damages the salivary glands, reducing saliva production. This can lead to difficulties in speaking, tasting, chewing, and swallowing, as well as an increased risk of dental problems¹³. Patients undergoing radiation therapy are often advised to stay hydrated and may be prescribed saliva substitutes or stimulants.
Choice C reason : Radiation to the neck might damage the thyroid gland, leading to hypothyroidism. Symptoms of thyroid problems due to radiation can include fatigue, weight gain, feeling cold, and having dry skin or hair³. Regular monitoring of thyroid function is recommended for patients who have received radiation therapy in the neck area.
Choice D reason : Lymphedema is swelling that can occur when radiation therapy affects the lymph nodes and vessels, impeding the flow of lymph fluid. In the context of neck radiation, this can lead to swelling in the neck and face³. Management includes physical therapy, compression garments, and careful skin care to prevent infection.
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