Choice A reason:

Ascites is not caused by an infection in the abdominal cavity. It is the result of fluid accumulation.

Choice B reason:

This statement is correct. Ascites is caused by the accumulation of excess fluid in the abdominal cavity, usually due to liver disease or other conditions that affect fluid balance in the body.

Choice C reason:

Blockage in the bile ducts may cause jaundice or other symptoms but is not the primary cause of ascites.

Choice D reason:

Ascites is not a genetic disorder and is not inherited from one's parents. It is a condition that develops due to various underlying medical conditions.

Choice A reason:

Avoiding all physical activities is not recommended. Moderate physical activity can actually help improve circulation and fluid balance in the body.

Choice B reason:

This statement is correct. Limiting salt intake in the diet can help reduce fluid retention in clients with ascites, as excess sodium can contribute to fluid accumulation.

Choice C reason:

Increasing fluid intake may worsen fluid retention in clients with ascites. Clients with this condition should follow their healthcare provider's recommendations for fluid restriction.

Choice D reason:

A high-protein diet is not specifically indicated to promote reabsorption of fluid in the abdomen. It is essential for clients with cirrhosis and ascites to follow a balanced diet that meets their individual nutritional needs.

Choice A reason:

Administering prescribed diuretics is essential in managing ascites, but it may not immediately address the client's respiratory distress.

Choice B reason:

This statement is correct. Elevating the head of the bed can improve respiratory mechanics and ease breathing for a client experiencing respiratory distress due to ascites.

Choice C reason:

Providing oxygen therapy is important for clients with respiratory distress, but it may not directly address the underlying cause of the distress in this situation.

Choice D reason:

Deep breathing exercises are beneficial for promoting lung expansion, but they may not be the priority in a client experiencing severe respiratory distress.

Choice A reason:

Increased urine output and dehydration are not early signs of ascites progression. Ascites involves fluid accumulation in the abdominal cavity, not fluid loss through the urinary system.

Choice B reason:

Weight loss and decreased abdominal girth are not early signs of ascites progression. Ascites typically leads to increased abdominal girth and swelling.

Choice C reason:

This statement is correct. Visible abdominal swelling and distention are early signs of ascites progression. As fluid accumulates in the abdominal cavity, the abdomen may become visibly swollen and distended.

Choice D reason:

Reduced ankle edema and lower extremity swelling are not early signs of ascites progression. Ascites primarily affects the abdominal cavity, not the extremities.

Choice A reason:

This statement is correct. Avoiding alcoholic beverages is essential for clients with cirrhosis to prevent further liver damage and fluid accumulation leading to ascites.

Choice B reason:

Increasing sodium intake is not recommended for clients with ascites, as excess sodium can contribute to fluid retention.

Choice C reason:

Engaging in strenuous physical activities may not be appropriate for clients with cirrhosis and ascites, as excessive exertion can worsen fluid retention and increase the risk of complications.

Choice D reason:

A high-fat diet is not recommended for clients with cirrhosis and ascites. A balanced diet with appropriate protein and carbohydrate intake is more appropriate for managing this condition.

Choice A reason:

Heart failure can lead to fluid retention in the body, but it is not the most common cause of ascites. Liver disease, such as cirrhosis, is the leading cause of ascites.

Choice B reason:

Kidney disease can result in fluid retention, but it is not the primary cause of ascites.

Choice C reason:

Lung cancer is not a common cause of ascites. Liver disease, particularly cirrhosis, is the most prevalent reason for this condition.

Choice D reason:

This statement is correct. Liver disease, particularly cirrhosis, is the leading cause of ascites due to its impact on fluid balance in the body.

Choice A reason:

Excessive alcohol consumption can contribute to kidney damage, but it is not the primary cause of ascites in individuals with chronic alcohol abuse.

Choice B reason:

Increased bile production and obstruction are not directly related to the development of ascites in clients with alcohol abuse.

Choice C reason:

This statement is correct. Chronic alcohol abuse can lead to liver damage, particularly cirrhosis, which impairs the liver's ability to regulate fluid balance, leading to ascites.

Choice D reason:

Heart failure can result in fluid overload, but it is not directly related to the development of ascites in individuals with alcohol abuse.

Choice A reason:

Elevated blood glucose levels and insulin resistance are not directly related to the development of ascites in clients with hepatitis C.

Choice B reason:

Impaired blood clotting and increased bleeding tendencies are not directly associated with the development of ascites in clients with hepatitis C.

Choice C reason:

Altered immune response and increased infection risk are not the primary factors contributing to ascites in clients with hepatitis C.

Choice D reason:

This statement is correct. Chronic hepatitis C infection can lead to liver inflammation and fibrosis, which, in turn, can progress to cirrhosis, increasing the risk of developing ascites.

Choice A reason:

Coughing and wheezing during physical activity are typical symptoms of congestive heart failure (CHF), but they do not directly indicate the presence of ascites.

Choice B reason:

Rapid and irregular heart rate at rest is a common manifestation of congestive heart failure (CHF) but does not directly indicate the presence of ascites.

Choice C reason:

This statement is correct. Ascites is characterized by the accumulation of fluid in the abdominal cavity, leading to swelling and distention in the lower abdomen.

Choice D reason:

Cold and clammy extremities are not typical manifestations of ascites and are not directly related to fluid overload in congestive heart failure (CHF).

Choice A reason:

Regulation of blood glucose levels is not a primary function of the kidneys in fluid balance. It is primarily related to the endocrine system and insulin regulation.

Choice B reason:

Maintenance of acid-base balance is a critical function of the kidneys but is not directly related to fluid balance leading to ascites.

Choice C reason:

Production of red blood cells occurs in the bone marrow, not the kidneys. While the kidneys produce erythropoietin, a hormone that stimulates red blood cell production, this is not the primary function related to fluid balance.

Choice D reason:

This statement is correct. The kidneys' primary function related to fluid balance is filtration and excretion of waste products and excess fluid, which helps maintain proper fluid balance in the body. In chronic kidney disease (CKD), impaired kidney function can lead to fluid retention and contribute to the development of ascites.

Choice A reason:

Increased urine output and dehydration are not typical findings in clients with ascites. Ascites involves fluid accumulation in the abdominal cavity, not fluid loss through the urinary system.

Choice B reason:

This statement is correct. Visible abdominal swelling and distention are characteristic signs of ascites, indicating the accumulation of fluid in the abdominal cavity.

Choice C reason:

Dry, cracked skin and itching are not specific to ascites and may be related to other conditions such as skin disorders or dehydration.

Choice D reason:

Rapid and irregular heart rate is not directly related to ascites. It may be associated with other conditions such as heart disease or infection.

Choice A reason:

Pleural effusion is fluid accumulation in the pleural cavity (around the lungs), and it can be associated with ascites, but it is not the specific complication described in the scenario.

Choice B reason:

Pneumonia is a lung infection and is not directly related to the difficulty breathing and increased respiratory rate described in the client with ascites.

Choice C reason:

This statement is correct. Pulmonary edema is a potential complication of ascites in which excess fluid accumulates in the lungs, leading to difficulty breathing and an increased respiratory rate.

Choice D reason:

Atelectasis is the collapse of part or all of a lung, and while it can be associated with difficulty breathing, it is not directly related to ascites.

Choice A reason:

Increased liver enzyme levels are not directly related to the abdominal pain and discomfort experienced by the client with ascites. Elevated liver enzymes indicate liver damage, but they do not cause abdominal pain.

Choice B reason:

Gallstone formation in the gallbladder is not directly related to the abdominal pain and discomfort experienced by the client with ascites.

Choice C reason:

This statement is correct. The abdominal pain and discomfort experienced by the client with ascites are primarily due to the stretching of the abdominal wall from the accumulation of fluid in the abdominal cavity.

Choice D reason:

Inflammation of the pancreas (pancreatitis) is not directly related to the abdominal pain and discomfort experienced by the client with ascites.

Choice A reason:

Mild ankle edema is not uncommon in clients with fluid retention, such as ascites. While it requires monitoring, it does not indicate an immediate need for intervention.

Choice B reason:

Moderate abdominal distention is a common finding in clients with ascites and should be monitored, but it does not require immediate intervention.

Choice C reason:

Complaints of thirst and dry mouth may indicate dehydration, which should be addressed, but it does not require immediate intervention as other options.

Choice D reason:

This statement is correct. Respiratory distress and cyanosis are concerning findings in a client with ascites, as they may indicate severe pulmonary edema or other respiratory complications that require immediate intervention and medical attention.

Choice A reason:

Electrolyte imbalances can occur in clients with ascites, but they are not directly related to the symptoms of fatigue and weakness described by the client.

Choice B reason:

Iron deficiency anemia may be present in clients with chronic liver disease, but it is not the primary cause of the client's fatigue and weakness in this scenario.

Choice C reason:

Hepatic encephalopathy is a complication of liver disease, but it typically presents with neurological symptoms such as confusion, altered mental status, and behavior changes, not fatigue and weakness.

Choice D reason:

This statement is correct. Fatigue and weakness are common symptoms in clients with chronic liver disease and ascites, and they can be related to malnutrition, which is often seen in these clients due to poor appetite, nutrient malabsorption, and other factors related to liver dysfunction.

Choice A reason:

An electrocardiogram (ECG) is used to assess heart rhythm and electrical activity, not to visualize ascites.

Choice B reason:

A chest X-ray is not specific to visualizing abdominal fluid accumulation and is not commonly used for diagnosing ascites.

Choice C reason:

This statement is correct. Abdominal ultrasound is commonly used to visualize and assess the presence of ascites by providing real-time images of the abdominal cavity, allowing healthcare providers to identify fluid accumulation.

Choice D reason:

A complete blood count (CBC) is a blood test that evaluates the number and types of blood cells. While it may be useful for other diagnostic purposes, it is not used to visualize ascites.

Choice A reason:

Inserting a tube into the bladder to drain urine is not related to paracentesis, which involves withdrawing fluid from the abdominal cavity.

Choice B reason:

This statement is correct. Paracentesis is a procedure that involves inserting a needle into the abdomen to withdraw fluid from the abdominal cavity, typically to diagnose or relieve ascites.

Choice C reason:

Administering a contrast dye and performing an X-ray is not part of paracentesis and is not used to diagnose ascites.

Choice D reason:

Injecting medication into a joint for pain relief is not related to paracentesis or the management of ascites.

Choice A reason:

Elevated blood glucose levels are not typically associated with ascites. Ascites is primarily related to fluid accumulation in the abdominal cavity, not glucose levels.

Choice B reason:

Increased white blood cell count may indicate infection or inflammation but is not directly related to the presence of ascites.

Choice C reason:

This statement is correct. Low albumin levels are commonly associated with ascites. Albumin is a protein produced by the liver that helps maintain fluid balance in the body. In liver disease, albumin levels may decrease, leading to fluid retention and the development of ascites.

Choice D reason:

Elevated thyroid-stimulating hormone (TSH) is not directly related to the presence of ascites.

Choice A reason:

This statement is correct. Magnetic Resonance Imaging (MRI) is commonly used to evaluate the liver and abdominal organs, providing detailed images that can help assess the severity and extent of ascites in clients with cirrhosis.

Choice B reason:

An electroencephalogram (EEG) is used to assess brain activity and is not directly related to the evaluation of ascites in clients with cirrhosis.

Choice C reason:

Positron Emission Tomography (PET) scan is used to visualize metabolic activity in body tissues and is not commonly used for evaluating ascites.

Choice D reason:

Bone Density Scan (DEXA scan) is used to assess bone health and is not directly related to the evaluation of ascites in clients with cirrhosis.

Choice A reason:

This statement is correct. Endoscopy can be used to visualize the upper gastrointestinal tract and assess for potential sources of bleeding or varices in the esophagus, which can be related to ascites in clients with liver disease.

Choice B reason:

Cardiac catheterization is used to assess the heart and blood vessels and is not directly related to determining the underlying cause of ascites.

Choice C reason:

Lumbar puncture is performed to obtain cerebrospinal fluid for diagnostic purposes and is not typically used to evaluate ascites.

Choice D reason:

Pulmonary function tests are used to assess lung function and are not directly related to determining the underlying cause of ascites.

Choice A reason:

Administering diuretics may be part of the management plan, but it may not provide immediate relief to the client experiencing discomfort and difficulty breathing.

Choice B reason:

Elevating the head of the bed can help improve respiratory function, but placing the client in a side-lying position is more effective for facilitating fluid drainage from the abdomen and providing immediate relief to the client with ascites.

Choice C reason:

Deep breathing exercises are beneficial for improving lung capacity, but they may not provide immediate relief to the client experiencing discomfort and difficulty breathing due to ascites.

Choice D reason:

This statement is correct. Placing the client in a side-lying position helps to facilitate fluid drainage from the abdomen and can provide immediate relief to the client with ascites who is experiencing discomfort and difficulty breathing.

Choice A reason:

Limiting protein intake is not typically recommended for clients with ascites, as protein is essential for maintaining muscle mass and overall health.

Choice B reason:

Avoiding foods high in potassium is important for clients with kidney problems, but it is not directly related to reducing fluid accumulation in the abdominal cavity for clients with ascites.

Choice C reason:

This statement is correct. Reducing sodium intake is essential to minimize fluid retention and help manage ascites. High sodium levels in the diet can lead to increased fluid retention in the body, exacerbating the accumulation of fluid in the abdominal cavity.

Choice D reason:

Increasing carbohydrate consumption for sustained energy is not directly related to reducing fluid accumulation in the abdominal cavity for clients with ascites.

Choice A reason:

Withholding all oral medications on the day of the procedure may not be necessary and should be determined by the healthcare provider's instructions based on the specific medications the client is taking.

Choice B reason:

Administering an analgesic to the client before the procedure may be appropriate to relieve pain, but it should be prescribed and administered by the healthcare provider.

Choice C reason:

This statement is correct. Ensuring that the client has emptied the bladder before the paracentesis procedure is important to prevent any potential complications during the procedure.

Choice D reason:

Fasting for at least 12 hours before the procedure may not be necessary for a paracentesis, as it is typically a minor procedure and does not require prolonged fasting.

Choice A reason:

Muscle weakness and fatigue are not commonly associated with spironolactone use.

Choice B reason:

Increased urine output and dehydration may occur with diuretics, but spironolactone is a potassium-sparing diuretic, so excessive urine output and dehydration are less likely to occur with this medication.

Choice C reason:

Hypotension and dizziness are potential side effects of some diuretics, but they are not specific to spironolactone use.

Choice D reason:

This statement is correct. Spironolactone is a potassium-sparing diuretic, which means it can lead to hyperkalemia (elevated potassium levels) if not monitored carefully. Hyperkalemia can cause irregular heart rhythms and other serious complications.

Choice A reason:

Hypoglycemia and confusion are not commonly associated with therapeutic paracentesis. They may be related to other factors or underlying conditions in the client.

Choice B reason:

This statement is correct. After therapeutic paracentesis, the client may experience hypovolemia (decreased blood volume) due to the removal of a large amount of fluid. This can lead to decreased urine output and other signs of fluid depletion.

Choice C reason:

Hyperglycemia and increased thirst are not directly related to therapeutic paracentesis and are not commonly associated with this procedure.

Choice D reason:

Hypothermia and shivering are not typical complications of therapeutic paracentesis. The procedure is performed under controlled conditions to minimize the risk of temperature-related complications.

Choice A reason:

Encouraging the client to lie flat in bed may worsen abdominal distention and discomfort. It is better to promote positions that facilitate fluid drainage, such as elevating the head of the bed or placing the client in a side-lying position.

Choice B reason:

Administering laxatives may not be appropriate for ascites management and could lead to electrolyte imbalances. It is essential to manage bowel movements cautiously, considering the client's fluid and electrolyte status.

Choice C reason:

This statement is correct. Assisting the client with regular and gentle ambulation can help facilitate fluid movement and reduce abdominal distention. Movement helps stimulate peristalsis and may improve drainage of fluid from the abdominal cavity.

Choice D reason:

Applying cold packs to the abdomen may provide temporary relief for localized pain but will not directly address the underlying issue of ascites or reduce abdominal distention.

Choice A reason:

Hypoglycemia and confusion are not commonly associated with spironolactone use. They are unrelated to this medication.

Choice B reason:

This statement is correct. Spironolactone is a potassium-sparing diuretic, and one of its potential complications is hyperkalemia (elevated potassium levels). Hyperkalemia can lead to irregular heart rhythms and other serious cardiac problems.

Choice C reason:

Hypotension and dizziness may be potential side effects of certain diuretics but are not specific to spironolactone use.

Choice D reason:

Hypernatremia (elevated sodium levels) and increased thirst are not typically associated with spironolactone use.

Choice A reason:

This statement is correct. Measuring abdominal girth and documenting findings are essential to monitor changes in fluid accumulation and assess the effectiveness of interventions.

Choice B reason:

Elevating the client's legs may help with edema in the lower extremities but will not directly address the fluid accumulation in the abdominal cavity.

Choice C reason:

Administering diuretics may be part of the management plan for ascites, but it may not be the initial intervention to address the client's current condition.

Choice D reason:

Applying an abdominal binder may be beneficial in certain cases, but it will not directly address the underlying cause of ascites or reduce fluid accumulation in the abdomen.

Choice A reason:

This statement is correct. Weighing the client daily and recording the weight in the chart is an essential intervention to monitor fluid balance and detect any changes in body weight, which can indicate fluid retention or loss.

Choice B reason:

Measuring vital signs every four hours is important for assessing the client's overall condition, but it does not directly monitor fluid balance or hydration status.

Choice C reason:

Assessing urine output hourly is important, especially for clients with ascites who may have altered kidney function. However, it may not provide a comprehensive assessment of the client's overall fluid balance.

Choice D reason:

Restricting fluid intake may not be appropriate for all clients with ascites, as fluid restriction could lead to dehydration and further imbalances in fluid and electrolyte levels.

Choice A reason:

Monitoring the client's blood pressure during the procedure is essential, but the nurse should prioritize administering an analgesic before the paracentesis to reduce pain and ensure the client's comfort during the procedure.

Choice B reason:

This statement is correct. Administering an analgesic before the procedure can help reduce pain and discomfort associated with paracentesis.

Choice C reason:

Restricting the client's fluid intake before the procedure is not necessary, as paracentesis is typically performed to remove fluid from the abdominal cavity and provide relief for the client.

Choice D reason:

Maintaining a supine position during the procedure is not required. The nurse should position the client comfortably, which may include elevating the head of the bed or placing the client in a side-lying position to facilitate fluid drainage.

QUESTION