HESI Case Study: Cirrhosis

Based on the prolonged APTT and PT/INR what clinical manifestation would the nurse anticipate visualizing upon assessment?

Petechiae

The nurse discusses the situation with another nurse who states that the client should have been sedated and restrained to keep them from leaving. In which situations is the use of physical restraints appropriate? (Select all that apply. One, some, or all options may be correct.)

-A combative and agitated client who is pulling at the indwelling catheters and IV lines. -A client who is at high risk for injury to self for whom no other safety measures have been successful. -A disoriented client who is trying to dislodge a tracheotomy tube.

Nursing care for the client focuses on conserving strength while maintaining muscle strength and tone. Which interventions should the RN/PN include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

-Assess pressure areas while turning every 2 hours. -Space nursing care to provide uninterrupted periods of rest. -Increase activity as tolerated.

Which nursing interventions are important prior to a paracentesis? (Select all that apply. One, some, or all options may be correct.)

-Ensure the client has signed a consent. -Instruct the client to empty their bladder. -Position the client in an upright position. -Apply sphygmomanometer to monitor blood pressure.

The nurse provides additional discharge teaching regarding lifestyle management. Which information should the nurse provide to the client? (Select all that apply. One, some, or all options may be correct.)

-Get plenty of rest and regular exercise. -Avoid the consumption of raw shellfish. -Consider joining an Alcoholic Anonymous (AA) group.

With a confirmed diagnosis of Laennec's cirrhosis, which assessment finding warrants immediate intervention? (Select all that apply. One, some, or all options may be correct.)

-Hematemesis -Melena

The treatment goal for cirrhosis is to slow the progression, prevent and treat any complications. Which interventions are most important for the nurses to include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

-Stress the importance of following a low sodium diet. -Empasize the need for B-complex vitamins. -Use moisturizing lotion to the skin to minimize scratching.

What is client's Glasgow Coma Scale rating obtained in this assessment? (Enter numerical value only. If rounding is necessary, round to the nearest whole number.)

8

What is the best approach for the nurse to use when responding to the client?

Ask the client why he feels people are judging them.

Which outcome indicates to the nurse that the lactulose and rifaximin are having the desired effect?

Increased mental alertness.

After the client undergoes the paracentesis, which nursing assessment warrants immediate intervention?

Increasing abdominal pain

Management of ascites is focused on sodium restriction diet, diuretic therapy, and fluid removal. While monitoring the client's fluid volume, what action should the nurse take?

Measure abdominal girth daily.

Which medication places the client at risk for hyperkalemia?

Spironolactone.

In the client with cirrhosis, which lab values does the nurse anticipate will be increased from the normal value? (Select all that apply. One, some, or all options may be correct.)

Total serum bilirubin AST/ALT APTT, PT/INR

The nurse positions the client in bed, calls for assistance, and assesses the client's vital signs and oxygen saturation level. Vital signs are: temperature 98.6° F (37° C), heart rate 148 beats/min, respirations 32 breaths/min, and blood pressure 70/36 mmHg and oxygen saturation level is 82%. In what order should the nurse perform the following actions? (Place in numerical order from first action through last action.)

1. Apply oxygen. 2. Ensure patency of the IV. 3. Notify the Rapid Response Team. 4. Transfer to critical care.

What intervention is a priority for the nurse?

Assist the client to bed and position them side lying.

The nurse continues the focused risk assessment by asking about etiologic factors related to cirrhosis. Which assessment finding provides the most likely indication that the client is at high risk for cirrhosis?

Previous diagnosis of Hepatitis C.

While administering the albumin infusion via a vein in the right hand, the nurse notes that the peripheral edema in the client's arms and hands has changed from 3+ to 2+. It is most important for the nurse to implement which intervention?

Continue the albumin infusion.

The nurse contacts the social worker who states they are too busy and unable to meet with the client. What is the best response by the nurse?

Emphasize the concern for the client's wellbeing and need for a social worker.

The client asks the nurse what makes everyone think that they are an alcoholic. The client states when they drink, they don't have to think about problems and that others must feel the same way. How should the nurse respond to the client?

Explain that their lab values are consistent with alcohol abuse.

Which nursing intervention best promotes accurate and effective communication?

Explain that there are several types of cirrhosis.

During the client's discharge education, which complication of cirrhosis should the nurse instruct the client to report immediately?

Hemoptysis after taking ibuprofen for a headache.

The client is minimally responsive and has a Glasgow Coma Scale rating of 8. The client is admitted with a diagnosis of hepatic encephalopathy. Which of the client's serum laboratory values requires intervention by the nurse?

Serum ammonia 157 mcg/dL (112.1 mcmol/L)

Which member of the inter-professional team is the best choice for the nurse to contact to help the client meet this goal?

Social worker

Who should the nurse notify of the client's action? (Select all that apply. One, some, or all options may be correct.)

The charge nurse. The client's HCP.