EXAM 4 | CH 53 | Liver problems
The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"
ANS: A, B, C, D, E, F The nurse would ask all of these questions because "baby boomers," people who use illicit drugs, people on hemodialysis, health workers, and prisoners are at a very high risk for hepatitis C. Additionally, individuals who received blood, blood products, or an organ transplant prior to 1992 before bloodborne disease screening of these products was mandated are at risk for hepatitis C.
In which way will the nurse respond to a patient diagnosed with hepatitis A who asks the nurse how this disease may have been contracted? "You may have consumed foods contaminated with the virus." "If you received a blood transfusion, you may have been exposed." "You may have been exposed if you had unprotected sexual intercourse." "The virus is airborne, so you may have contracted it from an infected person."
"You may have consumed foods contaminated with the virus." Rationale Hepatitis A is transmitted through the fecal-oral route and may be contracted by consuming contaminated foods. Hepatitis B, C, and D can be transmitted by blood transfusions received before 1992. Unprotected sex is a risk factor for hepatitis B and C (although the rate of sexual transmission with hepatitis C is very low in a monogamous relationship, it increases with multiple sex partners). There is no hepatitis virus that is airborne. p. 1166
The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)
ANS: A Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient's weight typically only decreases by less than 2 kg or 4.4 lb.
The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine
ANS: A, B, C, D, E, F All of these assessment findings are very common for a client who has late-stage cirrhosis due to biliary obstruction and poor liver function. The client has vascular lesions and excess fluid from portal hypertension.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."
ANS: B The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.
The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment
ANS: D A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the procedure to determine if the client has signs and symptoms of heart failure.
The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.
ANS: D For safety, the patient would void just before a paracentesis to prevent bladder damage to the procedure. The primary health care provider would have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table.
The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C
ANS: D Hepatitis C is the leading cause of cirrhosis and an also cause liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis.
Which condition is the nurse concerned about for a patient with Laennec cirrhosis who has an increased abdominal girth of 12 cm over the measured abdominal girth from a previous admission? Ascites Splenomegaly Hepatomegaly Esophageal varices
Ascites Rationale Patients with ascites have fluid in the peritoneal cavity, causing abdominal distention. A patient with an increase in abdominal girth should be evaluated for ascites. Esophageal varices are characterized by distention of esophageal vessels with increased risk for bleeding. Hepatomegaly is liver enlargement. Splenomegaly is spleen enlargement. p. 1160
Elevation of which laboratory value is associated with jaundice for a patient with hepatitis? Bilirubin Blood urea nitrogen (BUN) Alanine aminotransferase (ALT) Aspartate aminotransferase (AST)
Bilirubin Rationale Elevation of the bilirubin level correlates to yellow stain of the skin and sclera secondary to biliary obstruction and inflammation. BUN is a measure of renal function. AST and ALT are enzymes released in response to liver inflammation, but they do not correlate to jaundice. pp. 1161, 1169
The nurse will emphasize which point when instructing a patient with Laennec cirrhosis and portal hypertension? Do not consume any alcohol. Avoid saturated fats in the diet. Adhere to anticoagulant therapy. Reduce the amount of sodium in the diet.
Do not consume any alcohol. Rationale Laennec cirrhosis is otherwise known as alcoholic cirrhosis; it is caused by chronic alcohol use. Avoiding alcohol is essential to prevent further organ damage. Sodium restriction is recommended for ascites. Fat intolerance may occur with liver disease; however, reduction of alcohol is essential, especially with Laennec cirrhosis. Anticoagulants are not used to manage cirrhosis as there is a risk for bleeding related to prolonged international normalized ratio and prothrombin time. A low-sodium diet may be prescribed for a patient with early abdominal ascites as a means of controlling fluid accumulation; however, patients with late-stage cirrhosis are generally malnourished and have multiple dietary deficiencies, and sodium restriction is not the priority intervention for management of portal hypertension. p. 1165
The presence of immunoglobulin G (IgG) hepatitis A virus (HAV) antibodies would indicate which condition? Ongoing liver inflammation caused by HAV Active HAV infection with acute liver changes Immunity to HAV after previous HAV infection Possible hepatic cirrhosis as a result of HAV infection
Immunity to HAV after previous HAV infection Rationale The presence of IgG HAV antibodies indicates previous infection with HAV with resulting lifetime immunity. It does not indicate active infection. Immunoglobulin M (IgM) HAV antibodies are present during infection and ongoing inflammation. These antibodies are not diagnostic for hepatic cirrhosis. p. 1169
Which assessment finding would the nurse expect for a patient with hepatitis B? Select all that apply. One, some, or all responses may be correct. Itching Brown stool Tea-colored urine Recent influenza infection Right upper quadrant tenderness
Itching Tea-colored urine Right upper quadrant tenderness Rationale Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. The urine may be brown, tea-, or cola-colored in patients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. The stool in hepatitis may be tan or clay-colored. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. p. 1169
Which information would the nurse provide to an asymptomatic patient who is worried about possible hepatitis C virus (HCV) exposure several years ago? "Because you do not have signs of liver disease, you were probably not infected." "You have probably cleared the virus because you have not had symptoms." "You may be a carrier, but you will never have serious symptoms of the disease." "You may have serious long-term damage even without symptoms."
"You may have serious long-term damage even without symptoms." Rationale Patients exposed to HCV may develop chronic infection even without symptoms until the damage occurs over decades of infection. A patient is likely to be asymptomatic for months or years before the virus is detected. A carrier may or may not have serious symptoms of the disease. People with HCV do not clear the virus like those with hepatitis B virus (HBV). p. 1167
Which instruction would the nurse include when teaching a spouse and patient with hepatitis C about preventing the spread of infection? "Drink only bottled water." "Do not share toothbrushes." "Donate blood only once yearly." " you should use a separate bathroom"
"Do not share toothbrushes." Rationale Household members should not share any personal items with the patient infected with hepatitis C such as a toothbrush, razor, drinking glasses, drug paraphernalia, or any item where blood or body fluids could be encountered by others. Bottled water is not necessary as the patient is not at risk for contamination from tap water. The patient with hepatitis C may become a carrier, so blood should not be donated. There is no need to use a separate bathroom if the patient is continent of urine and stool and if the bathroom can be regularly disinfected. p. 1167
Which diet instruction would the nurse give to a patient with active hepatitis? "Follow a low-protein, low-fat diet." "Consume soft, easy-to-chew foods." "Eat small meals at frequent intervals." "Eat a normal diet with fluid restrictions."
"Eat small meals at frequent intervals." Rationale Small, frequent meals are often preferable to three standard meals for the patient with hepatitis because these patients often experience nausea and vomiting and dietary intolerance. The diet of the patient with hepatitis should be high in carbohydrates and calories with moderate amounts of fat and protein after nausea and anorexia subside; patients with liver disease should limit fat in the diet because of intolerance. Soft, easy-tochew foods are used with patients who have problems with dentition or chewing. Fluid restriction is only recommended in patients with severe ascites and anasarca. p. 1170
The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
ANS: A Although family members may be afraid that they will contract hepatitis C, the nurse would educate them about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needlesticks, unsanitary tattoo equipment, and sharing of intranasal drug paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.
XXXX The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding
ANS: A Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B.
The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."
ANS: A The purpose of administering lactulose to this patient is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The patient must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse would not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia
ANS: A, B, D, F Anemia and irritable bowel syndrome are unrelated to developing or worsening encephalopathy, which is caused by increased protein which breaks down into ammonia. Infection can cause hypovolemia which would increase serum protein concentration. Constipation and GI bleeding causes a large protein load in the intestines.
The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."
ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush would be used to prevent gum bleeding, and the client's nails would need to be trimmed short to prevent the patient from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.
The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy f. Respiratory therapy
ANS: A, C, D, F Care for a client who has hepatopulmonary syndrome would include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the patient in a prone position, on the patient's stomach. Although physical therapy may be helpful to a patient who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. However, respiratory support from a specialized therapist may be needed.
The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
ANS: B A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient's dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.
ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."
ANS: B Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.
The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis
ANS: B, C, D The client who has hepatitis C has complications that do not relate to the liver, including polyarthritis, myalgia, heart disease and vasculitis, renal disease, and cognitive impairment.
A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)
ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."
ANS: C Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.
The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."
ANS: C Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient's concerns. Attending AA may be appropriate, but this response doesn't address the client's concern. "Making peace" with the client's family may not be possible. This statement is not client-centered.
The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French
ANS: C The Patatin-like phospholipase domain containing 3 gene (PNPLA3) has been identified as a risk gene for cirrhosis, which occurs most often in Latinos when compared to other populations
XXXX The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug.
ANS: D Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.
The nurse will instruct a patient recently diagnosed with cirrhosis of the liver to avoid which substance to prevent further fibrosis of the liver and allow the liver to heal and regenerate? Select all that apply. One, some, or all responses may be correct. Alcohol Cigarettes Illicit drugs Fatty foods Acetaminophen
Alcohol Cigarettes Illicit drugs Acetaminophen Rationale For the patient with cirrhosis, it is important for the nurse to stress the need to avoid alcohol, smoking, illicit drugs, and acetaminophen to help prevent further fibrosis and scarring, allow healing and regeneration, prevent gastric and esophageal irritation, reduce the incidence of bleeding, and prevent other life-threatening changes. Although a healthy diet is important, fatty foods are not on the list of substances to avoid. p. 1165
The serum level of which enzyme is elevated in patients with biliary obstruction? Alkaline phosphatase Lactate dehydrogenase Alanine aminotransferase Aspartate aminotransferase
Alkaline phosphatase Rationale In patients with obstructive jaundice, the serum alkaline phosphatase level is elevated. Levels of serum aspartate aminotransferase, serum alanine aminotransferase, and lactate dehydrogenase are elevated in patients with hepatic cell destruction. p. 1160
Portal hypertension related to cirrhosis can result in which complication? Select all that apply. One, some, or all responses may be correct. Fever Ascites Hematuria Hemorrhoids Esophageal varices
Ascites Hemorrhoids Esophageal varices Rationale Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites because of excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process. p. 1156
Which term will the nurse use to document hand flapping that occurs a few moments after dorsiflexion of the hands when the arms are raised to shoulder level for a patient with liver disease? Asterixis Kehr sign Hyperreflexia Positive Babinski sign
Asterixis Rationale Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Kehr sign is reflected by increased abdominal pain and exaggerated by deep breathing, and it is referred to the right shoulder. Hyperreflexia refers to deep tendon reflexes that are overactive. Babinski sign is positive when the sole of the foot is stroked, the great toe points up, and the toes fan out. p. 1160
A transjugular intrahepatic portal-systemic shunt (TIPS) may be placed to prevent which complication for a patient with ascites? Hepatic encephalopathy Bleeding esophageal varices Spontaneous bacterial peritonitis Malnutrition and vitamin deficiency
Bleeding esophageal varices Rationale If medical management fails to control ascites, the primary health care provider may choose to divert ascites into the venous system by creating a shunt. Patients with ascites are poor surgical risks. The TIPS is a nonsurgical procedure that is used to control long-term ascites and reduce variceal bleeding. This is not performed to reduce the risk for hepatic encephalopathy or bacterial peritonitis, and it does not affect nutrition. p. 1163
Which factor may lead to hepatic encephalopathy for a patient with cirrhosis? Select all that apply. One, some, or all responses may be correct. Constipation Low-protein diet Decreased fluid volume GI bleeding Increased serum potassium
Constipation Decreased fluid volume GI bleeding Rationale Decreased fluid volume, constipation, and GI bleeding may cause hepatic encephalopathy in patients with cirrhosis. Other causes include a high-protein diet and decreased serum potassium levels. p. 1158
Which instruction would the nurse include when teaching a patient with viral hepatitis about care at home? Select all that apply. One, some, or all responses may be correct. Do not consume any alcohol. Consume a high-protein diet. Avoid carbonated beverages. Do not drive a car for 1 to 2 weeks. Monitor blood pressure and pulse daily. Avoid medications containing acetaminophen.
Do not consume any alcohol. Avoid medications containing acetaminophen. Rationale The patient with hepatitis should avoid all alcohol and check with the primary health care provider before taking any medication or vitamin, supplement, or herbal preparation. Acetaminophen is known to be hepatotoxic, so this should be avoided for patients with liver disease. The diet should be high in carbohydrates with moderate fat and moderate protein content. The patient may drive if he or she feels well. As hepatitis does not directly affect the cardiovascular system, there is no need to monitor vital signs. Although carbonated beverages may contribute to a sense of fullness, it is not required that they be absolutely excluded. p. 1171
Which laboratory finding signifies an immune response to liver disease? Elevated serum globulin Elevated serum ammonia Decreased serum albumin Decreased serum total protein
Elevated serum globulin Rationale An increase in the serum globulin level indicates an immune response to liver disease. A decrease in serum total protein signifies chronic liver disease, and a decrease in serum albumin signifies severe liver disease. The serum ammonia level is elevated in advanced liver disease or portal-systemic encephalopathy because the liver is unable to detoxify protein byproducts. p. 1161
Which factor increases a patient's risk for the development of hepatitis C? Consuming shellfish Traveling internationally Chronic alcohol consumption Employment in the health care field
Employment in the health care field Rationale Health care workers are at an increased risk for the development of hepatitis C because these workers can easily be exposed to blood and body fluids and are at risk for accidental needlestick injury. Hepatitis A can be contracted by consuming contaminated shellfish. Hepatitis E can be contracted by people who travel to countries with poor sanitation. Chronic alcohol consumption is a risk factor for cirrhosis, not hepatitis. p. 1167
Which intervention will the nurse include in the plan of care for a patient who is to undergo paracentesis later today? Measure and record drainage. Obtain informed consent for the procedure. Have the patient void before the procedure is performed. Report elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase levels.
Have the patient void before the procedure is performed. Rationale Voiding before the procedure prevents bladder injury. The drainage color and amount will be recorded after the procedure. The health care provider performing the procedure should discuss the intervention and potential complications with the patient and obtain informed consent. Liver enzymes are expected to be elevated; this is the purpose of the procedure. p. 1162
Which factor may lead to the development of hepatic encephalopathy in a patient with cirrhosis? Select all that apply. One, some, or all responses may be correct. Diarrhea Hypokalemia Hypertension High-protein diet Hypermagnesemia GI bleeding
Hypokalemia High-protein diet GI bleeding Rationale The development of hepatic encephalopathy is believed to be the result of the shunting of portal venous blood into the central circulation so that the liver is bypassed. A buildup of ammonia and gamma aminobutyric acid (GABA) is the result. Factors that may precipitate hepatic encephalopathy include a high-protein diet, infections, hypovolemia, hypokalemia, and constipation. GI bleeding that causes a large protein load in the intestine and medications such as hypnotics, opioids, sedatives, analgesics, and diuretics also contribute to encephalopathy. Diarrhea, hypertension, and hypermagnesemia are not known to be contributing factors for hepatic encephalopathy. p. 1158
Which assessment finding is consistent with a diagnosis of viral hepatitis? Icterus Dark-brown stool Light-colored urine Left upper quadrant tenderness
Icterus Rationale Findings in viral hepatitis include fever, jaundice, icterus (yellowish sclera), itching, clay-colored stool, dark urine, right upper quadrant tenderness, and nausea. p. 1169
Which finding would the nurse expect for a patient with late-stage cirrhosis? Select all that apply. One, some, or all responses may be correct. Icterus Currant jelly stool Swollen abdomen Elevated vitamin K Elevated amylase level Prolonged partial thromboplastin time (PTT)
Icterus Swollen abdomen Prolonged partial thromboplastin time (PTT) Rationale Icterus (yellow discoloration of the eye sclerae) and jaundice are often found with late-stage cirrhosis. The patient with cirrhosis may develop ascites, or fluid in the abdominal cavity. The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Late-stage cirrhosis causes vitamin deficiencies, especially fat-soluble vitamins A, D, E, and K. Cirrhosis is consistent with elevations of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase; amylase is typically elevated in pancreatitis. p. 1159
A positive result from a hepatitis B surface antigen (HBsAg) test would indicate which condition for a patient who was previously treated for the hepatitis B virus (HBV)? Infectious status of the patient Recurrence of infection Long-term liver damage Permanent immunity to HBV
Infectious status of the patient Rationale As long as the HBsAg is present, the patient is infectious and may be in a carrier state. It does not indicate permanent immunity, recurrence of infection, or long-term liver damage. p. 1167
Clay-colored stools and dark urine are typically characteristic of which complication of viral hepatitis? Hepatic carcinoma Cirrhosis of the liver Obstructive jaundice Intrahepatic obstruction
Intrahepatic obstruction Rationale Patients with hepatitis may develop intrahepatic obstruction, which will cause clay-colored stools and dark urine when the bile ducts are blocked. These findings may occur with hepatic obstruction in cirrhosis or carcinoma, but they do not necessarily indicate that these have occurred. Obstructive jaundice is another sign of intrahepatic obstruction. p. 1169
Which medication may cause intestinal bloating and cramping for a patient who is being treated for hepatic encephalopathy? Lactulose Rifaximin Alprazolam Metronidazole
Lactulose Rationale Lactulose is a laxative prescribed to treat hepatic encephalopathy by promoting excretion of ammonia in the stool by preventing absorption of ammonia in the colon. Lactulose causes abdominal cramping and bloating as side effects; therefore lactulose would be discontinued and replaced with another medication. Rifaximin is the most effective, safe, and long-term drug in the treatment of hepatic encephalopathy. A benzodiazepine, such as alprazolam, is used when the patient is experiencing alcohol withdrawal. Metronidazole is used as an antiseptic for intestinal infections and is not associated with abdominal cramping or bloating. p. 1164
When providing community education, the nurse would emphasize that which group should receive immunization for hepatitis B? Men who prefer sex with men Patients who work with shellfish Patients traveling to a third-world country Patients with elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
Men who prefer sex with men Rationale Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the patient is exposed to blood and body fluids during travel. Patients who have elevations of AST and ALT, which may indicate liver disease, should receive the vaccine; but men who have sex with men are at higher risk for contracting hepatitis B. p. 1167
Which person has the greatest risk for developing hepatitis A? Health care worker IV drug user Patient receiving hemodialysis Person who consumes raw oysters
Person who consumes raw oysters Rationale Undercooked or raw shellfish from contaminated waters and food handled by those who have not washed their hands thoroughly are at risk for hepatitis A. IV drug users, those undergoing hemodialysis, and health care workers are more at risk for hepatitis B or C, which is spread by blood or body fluids. p. 1166
Which term will the nurse use to document round, pinpoint, red-purple lesions for a patient with possible liver dysfunction? Petechiae Ecchymosis Telangiectasis Spider angioma
Petechiae Rationale The term petechiae is used for round, pinpoint, red-purple lesions. Ecchymoses are large purple, blue, or yellow patches. Telangiectasis and spider angioma are terms used for vascular lesions with a red center and radiating branches. pp. 1155, 1159
Which type of cirrhosis is caused by hepatitis C? Biliary Laennec Cholestatic Postnecrotic
Postnecrotic Rationale The hepatitis C virus causes postnecrotic cirrhosis. Laennec cirrhosis is caused by chronic alcoholism. Biliary cirrhosis is also called cholestatic cirrhosis; it is caused by chronic biliary obstruction or autoimmune disease. p. 1156
Which precaution is necessary to implement for a patient with hepatitis A? Enteric Precautions Droplet Precautions Protective isolation Standard Precautions
Standard Precautions Rationale Standard Precautions are used with all patients to prevent the spread of blood and body fluids, including the patient with hepatitis A. Standard Precautions prevent the spread of hepatitis A infection, which is spread by the fecal-oral route. Enteric precautions would be needed for patients with GI infection if Standard Precautions were not used. Droplet Precautions prevent the inhalation of respiratory droplets that spread infection, such as with meningitis. Protective isolation involves strict handwashing and limiting visitors and plants to protect the immunocompromised patient. p. 1168