Nurselabs Cirrhosis Questions
A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? "A. "You may have eaten contaminated restaurant food." b. "You could have gotten it by using I.V. drugs." c. "You must have received an infected blood transfusion." d. "You probably got it by engaging in unprotected sex.""
A. " You may have eaten contaminated resturant food." Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The hepatitis A virus (HAV) is a common infectious etiology of acute hepatitis worldwide. HAV is most commonly transmitted through the oral-fecal route via exposure to contaminated food, water, or close physical contact with an infectious person. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex.
A male client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking the client's history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is: a. tell me about your husbands alcohol usage b. is your husband being treated for TB c. has your husband recently fallen or injured his chest d. describe spices and condiments your husband uses on food.
A. " tell me about your husbands alcohol usage." A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous membrane at the junction of the esophagus and stomach. There is a strong relationship between ethanol usage, resultant vomiting, and a Mallory-Weiss tear. Mallory-Weiss tears account for an estimated 1-15% of cases of upper gastrointestinal bleeding. Although the age range varies widely, affected individuals are generally in middle age (40s-50s), and men reportedly have a higher incidence than women by a ratio of 2-4:1.
You're caring for a 28 y.o. woman with hepatitis B. She's concerned about the duration of her recovery. Which response isn't appropriate? A. Encourage her to not worry about the future. B. Encourage her to express her feelings about the illness. C. Discuss the effects of hepatitis B on future health problems. D. Provide avenues for financial counseling if she expresses the need.
A. Encourage her to not worry about the future Telling her not to worry minimizes her feelings. Contract with the patient regarding time for listening. Encourage discussion of feelings/concerns. Establishing time enhances trusting relationships. Providing an opportunity to express feelings allows the patient to feel more in control of the situation. Verbalization can decrease anxiety and depression and facilitate positive coping behaviors.
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with liver failure? A. Hypoalbuminemia B. Increased capillary permeability C. Abnormal peripheral vasodilation D. Excess renin release from the kidneys
A. Hypoalbuminemia Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess renin released from the kidneys aren't direct ramifications of liver failure.
Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: a. Pork b. Milk c.chicken d.Broccoli
A. Pork The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Thiamine helps turn carbohydrates into energy. It is required for the metabolism of glucose, amino acids, and lipids.
Which of the following measures should the nurse focus on for the client with esophageal varices? A. Recognizing hemorrhage. B. Controlling blood pressure. C. Encouraging nutritional intake. D. Teaching the client about varices.
A. Recognizing hemorrhage Recognizing the rupture of esophageal varices, or hemorrhage is the focus of nursing care because the client could succumb to this quickly. A patient with bleeding esophageal varices is to be considered in critical condition. Nursing management is aimed at assisting the physician in controlling bleeding and preventing shock and death.
You are developing a care plan for Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include? A. Administering a lactulose enema as ordered. B. Encouraging a protein-rich diet. C. Administering sedatives, as necessary. D. Encouraging ambulation at least four times a day.
A. administering a lactulose enema as ordered You may administer the laxative lactulose to reduce ammonia levels in the colon. Elevated ammonia levels disrupt the balance of excitatory and inhibitory neurotransmitters, further exacerbating neurological and motor function decline (Felipo, 2013). Patients who have high ammonia levels can experience HE, but in chronic liver failure, a higher ammonia level does not predict a more severe degree of HE.
Hepatic encephalopathy develops when the blood level of which substance increases? A. Ammonia B. Amylase C. Calcium D. Potassium
A. ammonia Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter systemic circulation, which carries it to the brain. Under normal conditions, ammonia is produced by bacteria in the gastrointestinal tract (e.g., breakdown product of amines, amino acids, purines, and urea) followed by metabolism and clearance by the liver. In the case of cirrhosis or advanced liver dysfunction, however, there is either a decrease in the number of functioning hepatocytes, portosystemic shunting, or both, resulting in decreased ammonia clearance and hyperammonemia.
Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? Select all that apply. A. assessing the client's neuologic status every 2 hours b. monitoring the client's hemoglobin and hematocrit c. evluating the client's serum ammonia level d. monitoring the client's handwriting daily e. preparing to insert an esophageal tamponade tube f. Making sure the client's fingernails are short.
A. assessing the client's neuologic status every 2 hours C. evaluating the client's serum ammonia levels D. monitoring the client's handwriting daily Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to convert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. Hepatic encephalopathy (HE) is a reversible syndrome observed in patients with advanced liver dysfunction. The syndrome is characterized by a spectrum of neuropsychiatric abnormalities resulting from the accumulation of neurotoxic substances in the bloodstream (and ultimately in the brain).
You're caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her? A. Asterixis B. Chvostek's sign C. Trousseau's sign D. Hepatojugular reflux
A. asterixis Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex. Asterixis is a clinical sign that describes the inability to maintain sustained posture with subsequent brief, shock-like, involuntary movements. This motor disorder is myoclonus characterized by muscular inhibition (whereas muscle contractions produce positive myoclonus).
Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax? A. Dyspnea and reduced or absent breath sound over the right lung. B. Tachycardia, hypotension, and cool, clammy skin. C. Fever, rebound tenderness, and abdominal rigidity. D. Redness, warmth, and drainage at the biopsy site.
A. dyspnea and reduced or absent breath sounds over the right lung Signs and symptoms of pneumothorax include dyspnea and decreased or absent breath sounds over the affected lung (right lung). A pneumothorax is defined as a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse.
You're caring for Jane, a 57 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Before her paracentesis, you instruct her to: A. Empty her bladder. B. Lie supine in bed. C. Remain NPO for 4 hours. D. Clean her bowels with an enema.
A. empty her bladder A full bladder can interfere with paracentesis and be punctured inadvertently. The preferred site for the procedure is in either the lower quadrant of the abdomen lateral to the rectus sheath. Placing the patient in the lateral decubitus position can aid in identifying fluid pockets in patients with lower fluid volumes. Ask the patient to empty his or her bladder before starting the procedure.
Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort? A. Give tepid baths. B. Avoid lotions and creams. C. Use hot water to increase vasodilation. D. Use cold water to decrease the itching.
A. give tepid baths For pruritus, care should include tepid sponge baths and use of emollient creams and lotions. Bathe or shower using lukewarm water and mild soap or nonsoap cleansers. Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
You observe changes in mentation, irritability, restlessness, and decreased concentration in a patient with cancer of the liver. Hepatic encephalopathy is suspected and the patient is ordered neomycin enemas. Which of the following information in the patient's history would be a contraindication of this order? A. Left nephrectomy B. Glaucoma in both eyes C. Myocardial infarction D. Peripheral neuropathy
A. left nephrectomy Neomycin prevents the release of ammonia from the intestinal bacteria flora and from the breakdown of red blood cells. Common side-effects of this drug are nephrotoxicity and ototoxicity. Patients with renal disease or renal impairment should not take this drug. A baseline serum BUN/creatinine should be obtained with subsequent periodical follow-up blood tests during chronic therapy to monitor for effects on renal function. Prompt discontinuation of the drug should occur with any signs of renal or otologic damage.
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet? A. Meats and beans B. Butter and gravies C. Potatoes and pasta D. Cakes and pastries
A. meats and beans Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted. Have about 1.2 to 1.5 grams of protein per kilogram of body weight. This means that a 154-pound (70-kilogram) man should eat 84 to 105 grams of protein per day. Look for non-meat protein sources such as beans, tofu, and dairy products when you can.
A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the following nursing assessment date would support this? A. oliguria and azotemia B. Metabolic Alkalosis C. Decreased urinary concentration D. weight gain of less than 1 lb per week
A. oliguria and azotemia Hepatorenal syndrome is a functional disorder resulting from a redistribution of renal blood flow. Oliguria and azotemia occur abruptly as a result of this complication. Confusion due to hepatic encephalopathy is likely the last and most severe stage of liver disease as a result of the liver failing to break down toxic metabolites. Most importantly these patients notice they urinate less frequently in smaller and smaller volumes as they become oliguric.
Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. passage of two or three soft stools daily B. Evidence of watery diarrhea C. daily deterioration in the client's handwriting D. appearance of frothy, foul smelling stools.
A. passage of two or three soft stools daily Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate the effectiveness of the drug. Lactulose, also known as 1,4 beta galactoside-fructose, is a non-absorbable synthetic disaccharide made up of galactose and fructose. The human small intestinal mucosa does not have the enzymes to split lactulose, and hence lactulose reaches the large bowel unchanged. Lactulose is metabolized in the colon by colonic bacteria to monosaccharides, and then to volatile fatty acids, hydrogen, and methane.
the nurse must be alert for complications with sengstaken-blakemore intubation including: A. pulmonary obstruction B. pericardiectomy syndrome C. pulmonary embolization D. Cor pulmonale
A. pulmonary obstruction Rupture or deflation of the balloon could result in upper airway obstruction. Esophageal rupture is a well-known but rarely reported fatal complication of the management of bleeding esophageal varices with the Sengstaken-Blakemore (SB) tube. The most common complications of esophageal balloon therapy for varices include aspiration, esophageal perforation, and pressure necrosis of the mucosa. The other choices are not related to the tube.
Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity? A. Restrict fluids. B. Encourage ambulation. C. Increase sodium in the diet. D. Give antacids as prescribed.
A. restrict fluids Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space. Restrict sodium and fluids as indicated. Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct dilutional hyponatremia.
You are caring for Rona, a 35-year-old female in a hepatic coma. Which evaluation criteria would be MOST appropriate A. the patient demostrates an increase in the LOC B. the paitent exhibits improved skin integrity C. the patient experiences no evident signs of bleeding D. THe patient verbalized decreased episodes of pain
A. the patient demostrates an increase in LOC Increased level of consciousness indicates resolving of a comatose state. Ongoing assessment of behavior and mental status is important because of the fluctuating nature of impending hepatic coma. Other options are important evaluations but do not evaluate a patient in a hepatic coma who is responding to external stimuli.
A nursing intervention for a patient with hepatitis B would include which of the following types of isolation. A. Universal precautions B. Blood transfusions C. Enteric isolation D. Strict isolation
A. universal precautions Universal precautions are indicated for the patient with hepatitis B. Hepatitis B is contracted via blood and blood products, body secretions, and punctures from contaminated needles. Universal precautions apply to blood and to other body fluids containing visible blood. Occupational transmission of HIV and HBV to healthcare workers by blood is documented. Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting.
For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be MOST important a. Allowing complete independence of mobility b. applying pressure to injection sites c. administering antibiotics as prescribed d. increasing nutritional intake
B applying pressure to injection sites The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Instruct patient/SO of signs and symptoms that warrant notification of health care provider: increased abdominal girth; rapid weight loss/gain; increased peripheral edema; increased dyspnea, fever; blood in stool or urine; excess bleeding of any kind; jaundice.
A male client has just been diagnosed with Hep A. On assessment, the nurse expects to note: A. severe abdominal pain radiating to the shoulder B. anorexia, nausea and vomiting C. eructation and constipation D. Abdomnial Ascites
B. Anorexia, nausea, and vomiting Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Acute hepatitis usually presents as a self-limited illness; development of fulminant hepatitis is rare. Typical symptoms of acute infection include nausea, vomiting, abdominal pain, fatigue, malaise, poor appetite, and fever; management is with supportive care.
A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? Select all that apply. a. range of motion every 4 hours b. turn and reposition every 2 hours c. abdominal and foot massages every 2 hours d. alternating air pressure mattress e. sit in chair for 30 minutes each shift
B. Turn and reposition every 2 hours D. alternating air pressure mattress Edematous tissue must receive meticulous care to prevent tissue breakdown. An air pressure mattress, careful repositioning can prevent skin breakdown. Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress. Use of emollient lotions and limiting use of soap for bathing may help.
which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis a. increase fluid intake to 3000 ml per day b. adequate bed rest c. bland diet d. administer antibiotics as ordered
B. adequate bed rest Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Institute bed red or chair rest during the toxic state. Provide a quiet environment; limit visitors as needed. Promotes rest and relaxation. Available energy is used for healing. Activity and an upright position are believed to decrease hepatic blood flow, which prevents optimal circulation to the liver cells.
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Relief of which symptom indicates that the paracentesis was effective? A. Pruritus B. Dyspnea C. Jaundice D. Peripheral Neuropathy
B. dyspnea Ascites put pressure on the diaphragm. Paracentesis is done to remove fluid and reduce pressure on the diaphragm. The goal is to improve the patient's breathing. The others are signs of cirrhosis that aren't relieved by paracentesis. Dyspnea from tense ascites might only be relieved with large-volume paracentesis. Care should also be taken with this procedure because patients with cirrhosis who have unrecognized cardiomyopathy can develop pulmonary edema following large-volume paracentesis.
A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level b. Elevated serum bilirubin level c. Elevated blood urea nitrogen level d. Decreased erythrocycle sedimentation rate"
B. elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. Baseline evaluation in a patient suspected to have viral hepatitis can be started by checking a hepatic function panel. Patients who have a severe disease can have elevated total bilirubin levels. Typically, levels of alkaline phosphatase (ALP) remain in the reference range, but if it is elevated significantly, the clinician should consider biliary obstruction or liver abscess.
Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects? a. jaundice b. hyperkalemia c. tachycardia d. constipation
B. hyperkalemia This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Spironolactone is a medication used in the management and treatment of hypertension and heart failure with some indications aside from cardiovascular disease. It is in the mineralocorticoid receptor antagonist class of drugs.
A patient with esophageal varices would reveal the following assessment a. increased blood pressure b. increased heart rate c. decreased respiratory rate d. increased urine output
B. increased heart rate Tachycardia is an early sign of compensation for patients with esophageal varices. Since the portal venous system has no valves, resistance at any level between the splanchnic vessels and the right side of the heart results in retrograde flow and elevated pressure. The collaterals slowly enlarge and connect the systemic circulation to the portal venous system.
What is the primary nursing diagnosis for a 4th to 10th-day postoperative liver transplant patient A. excess fluid volume B. Risk for rejection C. imparied skin integrity D. decreased cardiac output
B. risk for rejection Risk for rejection is always a possibility, especially during the 4th to 10th day postoperatively. LT patients are at risk for several complications. The primary care NP should be aware of these complications and needs to know when referral back to a transplant center or hepatologist is appropriate. The most serious issues are problems with the vasculature of the liver, biliary issues, rejection, and infection. Lab abnormalities—specifically elevation in alkaline phosphatase, alanine aminotransferase (ALT), and serum bilirubin levels—are usually the first indication of a problem in one or more of these areas.
Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include? A. "You'll need to lie on your stomach during the test." B. "You'll need to lie on your right side after the test." C. "During the biopsy, you'll be asked to exhale deeply and hold it." D. "The biopsy is performed under general anesthesia."
B. you will need to lie on your right side after the test After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce the risk of bleeding or bile leakage. The risk of fatal hemorrhage in patients without malignant disease is 0.04%, and the risk of nonfatal hemorrhage is 0.16%. In those with malignancy, the risk of nonfatal hemorrhage is 0.4% and 0.57% for nonfatal hemorrhage.
A patient is admitted with lacerated liver as a result of blunt abdominal trauma. Which of the following nursing interventions would not be appropriate for this patient? A. Monitor for respiratory distress. B. Monitor for coagulation studies. C. Administer pain medications as ordered. D. Administer normal saline, crystalloids as ordered.
C. administer pain medications as ordered Pain medication may mask signs and symptoms of hemorrhage, further decrease blood pressure, and interfere with assessment of neurologic status and additional abdominal injury. With the potential for hemorrhage, nonsteroidal anti-inflammatory drugs (NSAIDs) probably should be avoided. Acetaminophen with or without small quantities of mild narcotic analgesics may be all that should be prescribed initially. Minimize use of analgesics in patients who are admitted for observation.
Which of the following factors can cause hep a? A. Contact with infected blood B. Blood transfusion with infected blood C. Eating contaminated shellfish D. Sexual contact with an infected person
C. eating contaminated shellfish Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. The most common mode of transmission of hepatitis A is via the fecal-oral route from contact with food, water, or objects contaminated by fecal matter from an infected individual. It is more commonly encountered in developing countries where due to poverty and lack of sanitation, there is a higher chance of fecal-oral spread.
A client with advances cirrhosis has been diagnosed wiht hepatic encephalopathy. The nurse expects to assess for? A. Malasie b. stomatitis c. hand tremors d. weight loss
C. hand tremors Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. During the intermediate stages of HE, a characteristic jerking movement of the limbs is often observed (e.g., asterixis) when the patient attempts to hold arms outstretched with hands bent upward at the wrist.
Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? a. "jaundice is associated with pressure ulcer formation" b. jaundice impairs urea production, which produces pruiritis" c. Jaundice produces prurititis due to impaired bile acid excretion" d. jaundice leads to decreased tissue perfusion and subsequent breakdown"
C. jaundice produces pruititis due to impaired bile acid excretion Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Patients with jaundice often nominate pruritus as their most troublesome symptom to control and the symptom that has the most negative influence on their quality of life. The presence of pruritus can cause severe sleep deprivation resulting in lassitude, fatigue, depression, and suicidal ideation
The most important pathophysiological factor contributing to the formation of esophageal varices is: A. Decreased prothrombin formation. B. Decreased albumin formation by the liver. C. Portal hypertension. D. Increased central venous pressure.
C. portal hypertension As the liver cells become fatty and degenerate, they are no longer able to accommodate a large amount of blood necessary for homeostasis. The pressure in the liver increases and causes increased pressure in the venous system. As the portal pressure increases, fluid exudes into the abdominal cavity. This is called ascites.
The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a. dyspnea and fatigue d. ascites and orthopnea c. purpura and petechiae d. gynecomastia and testicular atrophy
C. purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Petechiae and purpura result from a wide variety of underlying disorders and may occur at any age. Petechiae are small (1-3 mm), red, non-blanching macular lesions caused by intradermal capillary bleeding. Purpura are larger, typically raised lesions resulting from bleeding within the skin
The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to: A. Check that the hemostat is on the bedside. B. Monitor IV fluids for the shift. C. Regularly assess respiratory status. D. Check that the balloon is deflated on a regular basis.
C. regularly assess respiratory status The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.
A female client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: A. Place the client in private room B. wear a mask when handling the client's bedpan C. Wash the hands after touching the client D. Wear a gown when providing personal care for a client
C. wash hands after touching the client To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client. Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material. They're indicated for patients with known or suspected infectious diarrhea or gastroenteritis.
Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client? A. Administering vitamin K subcutaneously B. Applying pressure when giving I.M. injections C. Decreasing the client's dietary protein intake D. Keeping the client's fingernails short and smooth
D. Keeping the client's fingernails short and smooth. The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Encourage the patient to adopt skin care routines to decrease skin irritation. One of the first steps in the management of pruritus is promoting healthy skin and healing of skin lesions
While palpating a female client's right upper quadrant (RUQ), the nurse would expect to find which of the following structures? A. sigmoid colon B. appendix C. spleen D. Liver
D. Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. Begin palpation over the right lower quadrant, near the anterior iliac spine. Palpate for the liver with one or two hands palm down moving upward 2-3 cm at a time towards the lower costal margin.
Which phase of hepatitis would the nurse incur strict precautionary measures at? A) icteric B) non-icteric C) post-icteric D) pre-icteric
D. Pre-icteric Pre-icteric is the infective phase and precautionary measures should be strictly enforced. However, most patients are not always diagnosed during this phase. Nonspecific symptoms occur; they include profound anorexia, malaise, nausea and vomiting, a newly developed distaste for cigarettes (in smokers), and often fever or right upper quadrant abdominal pain. Urticaria and arthralgias occasionally occur, especially in HBV infection.
A nurse is preparing to care for a female client with esophageal varices who just had a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times? a. an obturator b. kelly clamp c. an irrigation set d. a pair of scissors
D. a pair of scissors When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. Sengstaken-Blakemore tube placement is indicated for unstable patients with uncontrolled hemorrhage. Sengstaken-Blakemore tube placements can temporarily control the hemorrhage.
A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would MOST likely bring about hemostatis in the client are: A. Whole blood and albumin B. platlets and packed red blood cells C. fresh frozen plasma and whole blood D. cryoprecipitate and fresh frozen plasma
D. cryoprecipitate and fresh frozen plasma The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors.
A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care? A. measuring serum potassium for hyperkalemia B. Assess the client for hypervolemia C. measuring the client's weight weekly D. documenting precise intake and output
D. documenting precise intake and output For the client with ascites receiving diuretic therapy, careful intake and output measurement are essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. The most common adverse effect for any diuretic is mild hypovolemia, which can lead to transient dehydration and increased thirst. When there is an over-treatment with a diuretic, this could lead to severe hypovolemia, causing hypotension, dizziness, and syncope.
Rest periods and small frequent meals are indicated during the acute phase of hepatitis B. Monitor dietary intake and caloric count. Suggest several small feedings and offer the "largest" meal at breakfast. Large meals are difficult to manage when a patient is anorexic. Anorexia may also worsen during the day, making intake of food difficult later in the day.
D. my family knows that if i get tired and start vomiting, I may be getting sick again Hepatitis B can recur. Patients infected with HBV could be asymptomatic initially and, depending on the particular genotype, might not be symptomatic throughout the infected state. In these particular cases, careful history taking is important to establish a diagnosis. However, when symptomatic from acute HBV infection, patients can present with serum sickness-like syndrome manifested as fever, skin rash, arthralgia, and arthritis. This syndrome usually subsides with the onset of jaundice. Patients may also have fatigue, abdominal pain, nausea, and anorexia.
which rationale supports explaining the placement of an esophageal tamponade tube in a client who is hemorrhaging? a. allowing the client to help insert the tube b. beginning teaching for home care c. maintaining the client's level of anxiety and alertness d. obtaining cooperation and reducing fear
D. obtaining cooperation and reducing fear An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse, therefore, explains the placement to help obtain the client's cooperation and reduce his fear.
Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He's jaundiced and reports weakness. Which intervention will you include in his care? A. Regular exercise. B. A low-protein diet. C. Allow the patient to select his meals. D. Rest period after small, frequent meals.
D. rest period after small, frequent meals Rest periods and small frequent meals are indicated during the acute phase of hepatitis B. Monitor dietary intake and caloric count. Suggest several small feedings and offer the "largest" meal at breakfast. Large meals are difficult to manage when a patient is anorexic. Anorexia may also worsen during the day, making intake of food difficult later in the day.
Dr. Smith has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hep a b. hep b c. hep c d. hep d
a. Hep a Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. The most common mode of transmission of hepatitis A is via the fecal-oral route from contact with food, water, or objects contaminated by fecal matter from an infected individual. It is more commonly encountered in developing countries where due to poverty and lack of sanitation, there is a higher chance of fecal-oral spread.
When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client's family? A. Keeping the client in complete isolation B. Using good sanitation with dishes and shared bathrooms C. Avoiding contact with blood-soiled clothing or dressing D. Forbidding the sharing of needles or syringes
b. using good sanitation with dishes and shared bathrooms Hepatitis A is transmitted through the fecal-oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and the use of standard precautions. According to the WHO, the most effective way to prevent HAV infection is to improve sanitation, food safety, and immunization practices.
