Chapter 49: Assessment and Management of Patients With Hepatic Disorders 6
Respiratory assessment related to increased thoracic pressure
The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?
level of consciousness (LOC).
A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:
Peritonitis from bleeding in the liver caused by the liver biopsy
After being in remission from Hodgkin's disease for 18 months, a client develops a fever of unknown origin. A healthcare provider orders a liver biopsy to rule out advancing Hodgkin's disease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. What should the nurse suspect?
Asterixis
Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?
Arrange for a low air loss bed.
The nurse completing a plan of care for a client with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which nursing intervention is appropriate for this problem?
The client's hands flap back and forth when the arms are extended.
The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern?
Glucose metabolism Ammonia conversion Protein metabolism
A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply.
B
A client with a history of IV drug use is being treated for hepatitis, and presents today with jaundice and arthralgias. This client most likely has hepatitis:
100 to 126 grams
A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume?
Alcoholic cirrhosis
A nurse is teaching a client about the types of chronic liver disease. The teaching is determined to be effective when the client correctly identifies which type of cirrhosis as being caused by scar tissue surrounding portal areas?
