hepatic disorders

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 2kg a day 2. the client will have no increase in abdominal girth 3. the clients v/s will remain WNL 4. the client will receive a low sodium diet

2

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply. a) Infection at school b) Consumption of sewage-contaminated water or shellfish c) Ingestion of undercooked beef d) Sexual activity e) Suboptimal sanitary habits

a,b,d,e

What should you do to prevent infection in a patient who undergone liver transplantation? A. Place the patient in droplet isolation. B. Place the patient in a negative-pressure room. C. Avoid fresh flowers in a vase. D. Restrict visitors.

c

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Covering open sores b) Barrier protection during intercourse c) Vaccine d) Avoid sharing toothbrushes

c

The most common cause of esophageal varices includes which of the following? a) Asterixis b) Jaundice c) Portal hypertension d) Ascites

c

The patient has elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. What question is most important to ask the patient? A. Do you have intolerance to high fat foods? B. Do you have a history of pancreatitis? C. What medications are you taking? D. Do you smoke?

c

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Measurement of abdominal girth b) Palpation of abdomen for a fluid shift c) Weight d) Foul-smelling breath

d

The patient has been on the progressive care unit for the past 7 days with the diagnosis of liver failure. The nurse notes that the patient has developed a flapping tremor of the hand. The nurse should: 1. notify the provider because this is a sign that the disease is progressing. 2. continue to monitor the patient until more overt symptoms appear. 3. request that the provider increase the patient's protein intake to 60 g/day. 4. recognize that the tremors are normal for someone with liver disease.

1

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

1,2,3,4

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Purpura and petechiae b) Dyspnea and fatigue c) Gynecomastia and testicular atrophy d) Ascites and orthopnea

a

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? a) Daily weight and measurement of abdominal girth b) Palpation of abdomen for a fluid shift c) Auscultation of abdomen d) Assessment of oral cavity for foul-smelling breath

a

The patient is diagnosed with portal hypertension. The nurse would expect to see signs of: (Select all that apply.) A Hyperdynamic circulation (high-output failure). B Development of esophageal or gastric varices. C Decreased cardiac output. D A stable cardiac rhythm and rate. E clear lung sounds and increased organ perfusion

a,b

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Maintaining fluid volume b) Maintaining the airway c) Controlling bleeding d) Relieving the patient's anxiety

b

The patient with advanced cirrhosis asks you why his abdomen is so swollen. What knowledge is your response based on? A. A lack of clotting factors promotes the collection of blood in the abdominal cavity. B. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. C. Decreased peristalsis in the gastrointestinal tract contributes to gas formation and distention of the bowel. D. Bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

b

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) cholelithiasis. b) appendicitis. c) cirrhosis. d) peptic ulcer disease.

c

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a) Cure the cirrhosis. b) Promote optimal neurologic function. c) Reduce fluid accumulation and venous pressure. d) Treat the esophageal varices.

c

A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient? a) "You would not be scheduled for a transplant if there was a concern about rejection." b) "The problem of rejection is not as common in liver transplants as in other organ transplants." c) "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." d) "It is easier to get a good tissue match with liver transplants than with other types of transplants."

c

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Hepatitis A is frequently spread by sexual contact. b) Hepatitis B is transmitted primarily by the oral-fecal route. c) Infection with hepatitis G is similar to hepatitis A. d) Hepatitis C increases a person's risk for liver cancer.

d

The patient has end-stage chronic liver failure and has been vomiting "coffee-ground" material. The provider has ordered the insertion of a nasogastric tube. In inserting the tube, the nurse must be aware that: 1. esophageal varices may be present and rupture could lead to bleeding. 2. the splanchnic system does not develop collateral circulation in low-pressure veins. 3. portal hypertension is a result of varices formation. 4. the most common site for varices formation is the rectum.

1

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

2

The patient is admitted with severe ascites related to chronic liver disease. In trying to determine the cause of the ascites, the nurse should evaluate which laboratory values? 1. Blood glucose levels 2. Albumin levels 3. Fibrinogen levels 4. Clotting factors

2

The client has had a liver biopsy. which postprocedure intervention should the nurse implement? 1. instruct the client to void immediatly 2. keep the client NPO for 8 hours 3. place the client on the right side 4. monitor BUN and creatinine level

3

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsifex the client's foot 2. Measure the abdominal girth 3. Ask the client to extend the arms 4. Instruct the client to lean forward

3

which assessment question is priority for the nurse to ask the client dx with end stage liver failure secondary to alcoholic cirrhosis? 1. how many yrs 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

3

In what location would the nurse palpate for the liver? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant

c

The patient presents to the emergency department reporting nausea, vomiting, and right upper quadrant pain. What part of the patient's history is most important to further investigate? A. Consumes one or two beers every weekend B. Recently traveled to Canada C. Takes 10 extra-strength Tylenol daily D. Never immunized against hepatitis A

c

The patient with cirrhosis asks why he is taking Colace. What is the best explanation? A. Constipation increases the ammonia absorption. B. Colace enhances the retention of potassium. C. Straining can cause bleeding from varices. D. Colace promotes the instrinsic factor utilization

c

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? a) Portal hypertension b) Hepatitis C c) Esophageal varices d) Hepatic encephalopathy

d

Timothy is a client being treated for hepatitis in the infectious disease office where you practice nursing. He has a history of IV drug use. He presents today with jaundice and arthralgias. Timothy most likely has which type of hepatitis? a) Hepatitis A b) Hepatitis E c) Hepatitis C d) Hepatitis B

d

When planning care for a patient with cirrhosis, you will give highest priority to which nursing diagnosis? A. Imbalanced nutrition: less than body requirements B. Impaired skin integrity related to edema, ascites, and pruritus C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

d