The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?
Limit intake of fatty foods for one month after surgery.
Avoid crowds for first two months after surgery.
Notify the healthcare provider if edema occurs.
Increase activity and exercise gradually, as tolerated.
The Correct Answer is B
Rationale:
A. Limit intake of fatty foods for one month after surgery: While dietary modifications are beneficial for overall liver health, avoiding fatty foods is not the top priority post-transplant. The client’s greatest risk in the early period is infection due to immunosuppressive therapy.
B. Avoid crowds for first two months after surgery: Immunosuppressive medications increase the client’s susceptibility to infections. Avoiding crowds reduces exposure to viruses and bacteria, making this the most critical instruction for early post-transplant safety.
C. Notify the healthcare provider if edema occurs: Edema may signal fluid imbalance or graft dysfunction and should be reported, but it is a secondary concern compared to preventing infection, which can rapidly become life-threatening in immunocompromised individuals.
D. Increase activity and exercise gradually, as tolerated: Gradual resumption of physical activity is important for recovery, but it should be balanced with the need to prevent infection. Infection prevention remains the most urgent teaching point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Submit a sentinel event report to the research committee: A sentinel event refers to an unexpected occurrence involving death or serious injury, not a successful pilot study. Submitting such a report does not support positive practice change implementation.
B. Arrange inservice training through the education department: To ensure consistent and safe adoption of the new evidence-based practice, staff must be trained appropriately. Inservice sessions help standardize understanding and application across all shifts and units.
C. Invite data review by the quality improvement department: The QI department plays a key role in evaluating outcomes, ensuring ongoing effectiveness, and identifying areas for refinement. Their review supports evidence-based decision-making and broader facility implementation.
D. Propose clinical practice guidelines to the nursing committee: The nursing committee evaluates and approves practice changes for system-wide integration. Presenting guidelines ensures alignment with institutional policies and facilitates formal adoption of the new approach.
E. Obtain informed consent from clients who will receive care: Informed consent is not typically required when implementing standard evidence-based care unless the intervention is experimental. Since the pilot was successful and no longer a research study, consent is not necessary.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B,C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}
Explanation
Rationale:
- Avoidance: Avoidance of reminders of the trauma, including people, places, or conversations related to the event, is a core diagnostic criterion for PTSD. The client avoids visiting fellow platoon members, suggesting avoidance behavior linked to her combat trauma.
- Suicidal ideation: Thoughts of death or suicide are hallmark symptoms of MDD. The client was found writing a suicide note and planning to shoot herself, which strongly supports the diagnosis of MDD.
- Nightmares: Recurrent distressing dreams or nightmares related to the traumatic event are common in PTSD. The client reports frequent nightmares linked to her war experience.
- Feelings of guilt: Excessive guilt is common in MDD, often irrational and self-deprecating. In PTSD, survivors’ guilt is prevalent, especially when others died in the traumatic event, as expressed by the client lamenting that her life was spared over her comrades'.
- Lack of interest: Markedly diminished interest or pleasure in previously enjoyed activities is a core symptom of MDD. The client’s withdrawal from social connections reflects this loss of interest.
- Sleep disturbance: Insomnia is prevalent in GAD due to excessive worry, in MDD due to mood dysregulation, and in PTSD due to nightmares and hyperarousal. The client’s reported insomnia applies to all three conditions.
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