Exam 3: Liver Failure, Hepatitis

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. ' 5. Avoid any type of hepatotoxic medications.

ANS: 1, 2, 3 1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. 3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults. 4. Immune globulin injections are administered as postexposure prophylaxis (after being exposed to hepatitis B), but encouraging these injections is not a health promotion activity. 5. Hepatotoxic medications should be avoided in clients who have hepatitis or who have had hepatitis. The health-care provider prescribes medications, and the layperson does not know which medications are hepatotoxic.

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

ANS: 1, 2, 3, 4 1. Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. 2. Soft-bristle toothbrushes will help prevent bleeding of the gums. 3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use smallgauge needles. 5. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level not associated with vitamin K deficiency.

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

ANS: 1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop. 2. Hepatitis B virus is spread through contact with infected blood and body fluids. 3. Hepatitis C virus is transmitted through infected blood and body fluids. 4. Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea.

ANS: 4. "Flu-like" symptoms are the first complaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously 1. Clay-colored stools and jaundice occur in the icteric phase of hepatitis. 2. Normal appetite and itching occur in the icteric phase of hepatitis. 3. Fever subsides in the icteric phase, and the pain is in the right upper quadrant.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

ANS: 4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels. 1. Sodium is restricted to reduce ascites and generalized edema, not for hepatic encephalopathy. 2. Fluids are calculated based on diuretic therapy, urine output, and serum electrolyte values; fluids do not affect hepatic encephalopathy. 3. A diet high in calories and moderate in fat intake is recommended to promote healing.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

ANS: 4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands. 1. Eating after each other should be discouraged, but it is not the most important intervention. 2. Only bottled water should be consumed in third world countries, but this precaution is not necessary in American high schools. 3. Hepatitis B and C, not hepatitis A, are transmitted by sexual activity.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

ANS: 4. The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention. 1. The client should avoid alcohol to prevent further liver damage and promote healing. 2. Rest is needed for healing of the liver and to promote optimum immune function. 3. Clients with hepatitis need increased caloric intake, so this is a good statement.

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

ANS: 1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy. 2. Decreased albumin causes the client to develop ascites. 3. An enlarged spleen increases the rate at which RBCs, WBCs, and platelets are destroyed, causing the client to develop anemia, leukopenia, and thrombocytopenia, but not hepatic encephalopathy. 4. An increase in aldosterone causes sodium and water retention, resulting in the development of ascites and generalized edema.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

ANS: 1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP. 2. Applying emollient lotion will help prevent dry skin, which will help decrease pruritus; therefore, this would not require any intervention by the nurse. 3. Mittens will help prevent the client from scratching the skin and causing skin breakdown. This would not require intervention by the nurse. 4. The skin should be patted dry, not rubbed, because rubbing the skin will cause increased irritation. This action does not require intervention by the nurse.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

ANS: 1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily. 2. TPN is not routinely prescribed for the client with hepatitis; the client must lose a large of amount of weight and be unable to eat anything for TPN to be ordered. 3. Salt intake does not affect the healing of the liver. 4. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food intake.

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

ANS: 2. Adequate rest is needed for maintaining optimal immune function. 1. The client must avoid alcohol altogether, not decrease intake, to prevent further liver damage and promote healing. 3. Clients are more often anorexic and nauseated in the afternoon and evening; therefore, the main meal should be in the morning. 4. Diet drinks and juices provide few calories, and the client needs an increasedcalorie diet for healing.

The client diagnosed with liver problems asks the nurse, "Why are my stools claycolored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

ANS: 2. Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin. 1. The serum ammonia level is increased in liver failure, but it is not the cause of claycolored stools. 3. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but it does not affect the feces. 4. Vitamin deficiency, resulting from the liver's inability to detoxify vitamins, may cause steatorrhea, but it does not cause clay-colored stool.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

ANS: 2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume. 1. Two (2) kg is more than four (4) pounds, which indicates severe fluid retention and is not an appropriate goal. 3. Vital signs are appropriate to monitor, but they do not yield specific information about fluid volume status. 4. Having the client receive a low-sodium diet does not ensure the client will comply with the diet. The short-term goal must evaluate if the fluid volume is within normal limits.

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

ANS: 2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth. 1. This is a therapeutic response, and the nurse should provide factual information. 3. The nurse should not discourage complementary therapies. 4. This is a judgmental statement, and the nurse should encourage the client to ask questions.

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions.

ANS: 2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood. 1. Airborne Precautions are required for transmission occurring by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. 3. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with large-particle droplets generated during coughing, sneezing, talking, or suctioning. 4. Exposure Precautions is not a designated isolation category.

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

ANS: 2. The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin. 1. The nurse must notify the infection control nurse as soon as possible so treatment can start if needed, but this is not the first intervention. 3. Postexposure prophylaxis may be needed, but this is not the first action. 4. The infection control/employee health nurse will check the status of the client whom the needle was used on before the nurse stuck herself.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

ANS: 2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment. 1. Two to soft three stools a day indicates the medication is effective. 3. Diarrhea indicates an overdosage of the medication, possibly requiring the dosage to be decreased. The HCP needs to make this change in dosage, so the client understands the teaching. 4. The client should check the stool for bright-red blood as well as dark, tarry stool.

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (SengstakenBlakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

ANS: 2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue. 1. The client's throat is not anesthetized during the insertion of a nasogastric tube, so the gag reflex does not need to be assessed. 3. This laxative is administered to decrease the ammonia level, but the question does not say the client's ammonia level is elevated. 4. Esophageal bleeding does not cause the ammonia level to be elevated

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

ANS: 3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure. 1. Hypoalbuminemia (decreased albumin) and muscle wasting are metabolic effects, not gastrointestinal effects. 2. Oligomenorrhea is no menses, which is a reproductive effect, and decreased body hair is an integumentary effect. 4. Dyspnea is a respiratory effect, and caput medusae (dilated veins around the umbilicus) is an integumentary effect, although it is on the abdomen.

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

ANS: 3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure. 1. The client should empty the bladder immediately prior to the liver biopsy, not after the procedure. 2. Foods and fluids are usually withheld two (2) hours after the biopsy, after which the client can resume the usual diet. 4. Blood urea nitrogen (BUN) and creatinine levels are monitored for kidney function, not liver function, and the renal system is not affected with the liver biopsy.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

ANS: 3. The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed. 1. The laboratory technician draws serum blood studies, not the UAP. 2. The UAP can obtain the intake and output, but the nurse must evaluate the data to determine if the results are normal for the client's disease process or condition. 4. The ward clerk has specific training that allows the transcribing of health-care provider orders.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

ANS: 3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging. 1. The procedure is done in the client's room, with the client seated either on the side of the bed or in a chair. 2. The client should empty the bladder prior to the procedure to avoid bladder puncture, but there is no need for an indwelling catheter to be inserted. 4. The client does not have to hold the breath when the catheter is inserted into the peritoneum; this is done when obtaining a liver biopsy.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

ANS: 3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol. 1. It really doesn't matter how long the client has been drinking alcohol. The diagnosis of alcoholic cirrhosis indicates the client has probably been drinking for many years. 2. An advance directive is important for the client who is terminally ill, but it is not the priority question. 4. This is not a typical question asked by the nurse unless the client is malnourished, which is not information provided in the stem.

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

ANS: 3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client. 1. This is a therapeutic response and is used to encourage the client to verbalize feelings, but does not provide factual information. 2. This is passing the buck; the nurse should be able to answer this question. 4. This is the medical explanation as to why the medication dose is decreased, but it should not be used to explain to a layperson.