NUR2261 - Unit 2 - Cirrhosis

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy would the nurse assess this client? Select all that apply. One, some, or all responses may be correct. 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor

1 Mental confusion 4 Flapping hand tremors 5 Musty, sweet breath odor

The nurse is caring for a client with a history of alcoholism and cirrhosis who is hospitalized with severe dyspnea as a result of ascites. An increase in which process most likely caused the ascites? 1 Secretion of bile salts 2 Pressure in the portal vein 3 Interstitial osmotic pressure 4 Production of serum albumin

2 Pressure in the portal vein

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient reports right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's abdominal skin has multiple spider-shaped blood vessels.

ANS: B (Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.)

17. How should the nurse prepare a patient with ascites for paracentesis? a. Place the patient on NPO status. b. Assist the patient to lie flat in bed. c. Ask the patient to empty the bladder. d. Position the patient on the right side.

ANS: C (The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.)

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? a. Withhold both drugs. b. Administer both drugs. c. Administer the furosemide. d. Administer the spironolactone.

ANS: D (Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.)

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

ANS: D (TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.)

8. Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

ANS: D (The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.)

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

ANS: D (The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.)

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. A 58-yr-old patient who has compensated cirrhosis and reports anorexia b. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

ANS: C (This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.)

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? 1 Institute fall prevention and safety measures. 2 Evaluate coping skills. 3 Measure abdominal girth daily. 4 Test stool specimens for blood.

1 Institute fall prevention and safety measures.

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. Which intervention would the nurse do to prepare the client for the procedure? 1 Instruct the client to void. 2 Tell the client not to eat for 4 hours. 3 Give the client an analgesic. 4 Have the client turn to the lateral position.

1 Instruct the client to void.

The nurse is performing a physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe which skin conditions? Select all that apply. One, some, or all responses may be correct. 1 Vitiligo 2 Hirsutism 3 Melanosis 4 Ecchymoses 5 Telangiectasia

4 Ecchymoses 5 Telangiectasia

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

ANS: B (Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.)

For a patient who has cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Teaching the patient the prescribed diet

ANS: B (Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/VNs) or RNs.)

7. A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Have you taken corticosteroids?" b. "Do you have a history of IV drug use?" c. "Do you use any over-the-counter drugs?" d. "Have you recently traveled to another country?" The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

c. "Do you use any over-the-counter drugs?" (The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.)

The nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. Which does the nurse conclude is the probable cause of ascites? 1 Impaired portal venous return 2 Inadequate secretion of bile salts 3 Excess production of serum albumin 4 Decreased interstitial osmotic pressure

1 Impaired portal venous return

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item? 1 Black, tarry stools 2 Frequent nausea 3 Joining Alcoholics Anonymous 4 Pain that increases after meals

1 Black, tarry stools

The nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information would the nurse include in the teaching session? Select all that apply. One, some, or all responses may be correct. 1 Adhering to a low-carbohydrate diet 2 Avoiding aspirin and aspirin-containing products 3 Limiting alcohol consumption to two drinks weekly 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement

2 Avoiding aspirin and aspirin-containing products 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement

A client with cirrhosis of the liver has been taking chlorothiazide. The provider adds spironolactone to the client's medication regimen to prevent which condition? 1 Hyponatremia 2 Hypokalemia 3 Ascites 4 Peripheral neuropathy

2 Hypokalemia

Why would lactulose be prescribed for a client with a history of cirrhosis of the liver? 1 The desire to drink alcohol is decreased. 2 Diarrhea is controlled and prevented. 3 Elevated ammonia levels are lowered. 4 Abdominal distension secondary to ascites is decreased.

3 Elevated ammonia levels are lowered.

Which action will the nurse take to assess a client's response to serum albumin therapy for cirrhosis of the liver? 1 Monitor the client's vital signs. 2 Measure the client's urine output every half hour. 3 Obtain the client's weight at least once every day. 4 Determine the client's urine albumin level each shift.

3 Obtain the client's weight at least once every day.

A client with severe cirrhosis is hospitalized. The nurse discovers fetor hepaticus when the nurse performs which part of the client's assessment? 1 Assessment of the client's urine 2 Assessment of the client's stool 3 Assessment of the client's hands 4 Assessment of the client's breath

4 Assessment of the client's breath

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin

ANS: A (The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.)

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate? 1 No protein 2 Moderate protein 3 High protein 4 Strict protein restriction

2 Moderate protein

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention? 1 Weigh the client daily. 2 Restrict the client's oral fluid intake. 3 Measure the client's urine specific gravity. 4 Observe the client for increasing confusion.

4 Observe the client for increasing confusion.

Neomycin is prescribed for a client with cirrhosis. Which reason will the nurse explain is the purpose for taking this medication? 1 Prevents an infection 2 Limits abdominal distention 3 Minimizes intestinal edema 4 Reduces the blood ammonia level

4 Reduces the blood ammonia level

Which instruction would be included in a discharge plan for a client hospitalized with severe cirrhosis of the liver? 1 The need for a high-protein diet to avoid malnourishment 2 The use of a sedative for relaxation to decrease personal stress 3 The need to increase daily intake of oral fluids 4 The need to report personality changes to the primary health care provider

4 The need to report personality changes to the primary health care provider

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

ANS: A (The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.)

Which topic is most important to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Avoiding all alcohol use c. Maintaining good nutrition d. Using vitamin B supplements

ANS: B (The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.)

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

ANS: B (The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.)

What is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? a. Bilirubin levels b. Ammonia levels c. Potassium levels d. Prothrombin time

ANS: B (The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.)

A patient who has cirrhosis and esophageal varices is being treated with propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 130/80 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/min.

ANS: C (Because the purpose of -blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.)

Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient who was admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.

ANS: C (Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.)