12.C Liver Disease

The nurse is performing an assessment for a client diagnosed with cirrhosis. Which finding should lead the nurse to determine that treatment is​ effective? (Select all that​ apply.) A. Absence of bruising or bleeding B. Stable liver function tests C. Increasing abdominal girth measurements D. Increasing serum albumin levels E. Decreasing blood urea nitrogen levels

A, B, D ​Rationale: For treatment to be​ effective, liver function tests should remain stable during treatment. The client should exhibit the absence of bruising or bleeding. Serum albumin levels should increase. Abdominal girth measurements should decrease. Blood urea nitrogen levels are used to diagnose kidney​ failure, not liver failure.

Which information is most important for the nurse to include in the discharge teaching for a client diagnosed with cirrhosis of the​ liver? A. Physical therapy consult B. How to institute bleeding precautions C. Ways to increase fluid consumption D. Importance of​ high-impact aerobic exercise

B. How to institute bleeding precautions Rationale: The client diagnosed with cirrhosis is at risk for bleeding because the​ liver's ability to manufacture clotting factors is impaired. The client should be taught how to institute bleeding precautions. A referral for home health​ services, dietary​ consultation, social​ services, and counseling may be​ needed; a physical therapy consult is not. Ways to manage fatigue and conserve energy should be​ taught; the client should not engage in​ high-impact aerobic exercise. Cirrhosis affects water and salt regulation because of portal​ hypertension, hypoalbuminemia, and​ hyperaldosteronism, which causes fluid volume overload.​ Therefore, the client will most likely be on fluid restriction.

The nurse is caring for a client suspected of having hepatorenal syndrome. Which assessment finding leads the nurse to determine this is​ correct? A. Asterixis B. Esophageal varices C. Sodium retention D. Fever

C. Sodium retention ​Rationale: Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with portal systemic​ encephalopathy, and fever occurs with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.

The nurse is caring for a client experiencing severe ascites. Which collaborative intervention should the nurse​ expect? A. Gastric lavage B. Transjugular intrahepatic portosystemic shunt​ (TIPS) C. Insertion of​ Sengstaken-Blakemore tube D. Paracentesis

D. Paracentesis Rationale: For severe​ ascites, the treatment of choice is​ paracentesis, which is removal of fluid from the peritoneal cavity. The goal of this treatment is to reduce respiratory distress. A​ Sengstaken-Blakemore tube is used to treat bleeding esophageal varices. Gastric​ lavage, irrigation of the stomach with large quantities of normal​ saline, is performed to improve visualization of the stomach. The TIPS procedure is performed to relieve portal hypertension.

The nurse is discussing risk factors for cirrhosis with a group of community members. Which risk factor should the nurse include in the​ discussion? (Select all that​ apply.) A. Injection drug use B. Obesity C. Excessive alcohol use D. Hepatitis C infection E. Smoking

A, C, D Rationale: The leading risk factor for cirrhosis is excessive alcohol use. The use of injected drugs puts the client at risk of contracting viral hepatitis​ (B, C, or​ D). Obesity and smoking are not known risk factors for cirrhosis.

The graduate nurse is creating a care plan for a client diagnosed with cirrhosis. Which diagnosis assigned by the graduate nurse to the client should be questioned by the nursing​ preceptor? A. Skin​ Integrity: Impaired B. Fluid​ Volume: Deficient C. ​Nutrition, Imbalanced: Less than Body Requirements D. ​Protection: Ineffective

B. Fluid​ Volume: Deficient ​Rationale: Appropriate nursing diagnoses for a client with cirrhosis include Skin​ Integrity: Impaired due to pruritus as a result of bile salt deposits on the​ skin; ​Protection: Ineffective due to compromised mental​ status, and ​Nutrition, Imbalanced: Less than Body Requirements due to the​ client's salt and protein restrictions which may make the diet less palatable and appealing. Fluid​ Volume: Excess​, not Fluid​ Volume: Deficient​, is appropriate for a client with cirrhosis.​ (NANDA-I ©2014)

The nurse determines a client diagnosed with cirrhosis is at risk for bleeding. Which intervention is the priority for the nurse to include in the plan of​ care? A. Provide nutritional supplements. B. Monitor coagulation studies and platelet count. C. Administer antihistamines as prescribed. D. Administer albumin as prescribed.

B. Monitor coagulation studies and platelet count. Rationale: Monitoring coagulation studies and platelet count help determine if the client is bleeding or is at imminent risk for​ bleeding, and if there is a need for treatment. Antihistamines are used to reduce itching. Albumin is administered to increase plasma oncotic pressure and reduce edema and ascites. Providing nutritional supplements is important but does not affect the risk for bleeding.

The nurse is caring for a client diagnosed with portal hypertension. For which complication should the nurse​ monitor? A. Hepatic encephalopathy B. Fatty liver C. Esophageal varices D. Hepatitis C

C. Esophageal varices Rationale: In portal​ hypertension, the venous drainage of the gastrointestinal tract becomes​ congested, leading to esophageal varices. Hepatitis C is caused by a viral infection. Hepatic​ (portal systemic) encephalopathy is due to the accumulation of toxic substances in the​ bloodstream, related to liver failure.​ Steatohepatitis, also known as fatty​ liver, is a condition in which fat cells build up in the​ liver, leading to liver enlargement and cirrhosis.

The nurse cares for a client diagnosed with cirrhosis. Which clinical manifestation suggests to the nurse that the diagnosis is​ correct? (Select all that​ apply.) A. Ascites B. Splenomegaly C. Hepatic encephalopathy D. Hypertension E. Esophageal varices

A, B, C, E ​Rationale: Complications associated with cirrhosis include esophageal​ varices, splenomegaly,​ ascites, and hepatic​ (portal systemic) encephalopathy. Hypertension is not a complication associated with cirrhosis.

Which metabolic effect should the nurse expect to find in the client with liver​ disease? (Select all that​ apply.) A. Impaired bilirubin conversion B. Disrupted glucose metabolism C. Increased plasma oncotic pressure D. Impaired clotting factor production E. Increased blood flow to the liver

A, B, D Rationale: Liver disease causes many metabolic effects. Impaired clotting factor production results in bleeding and bruising. Disrupted glucose metabolism results in either hyperglycemia or hypoglycemia. Impaired bilirubin conversion and excretion result in jaundice. Other effects of liver disease include disrupted blood flow to the liver resulting in portal hypertension and decreased plasma oncotic pressure from impaired protein metabolism. This results in edema and ascites.

The nurse is caring for a client diagnosed with cirrhosis who has developed ascites. Which intervention should the nurse include in the plan of​ care? (Select all that​ apply.) A. Monitor intake and output. B. Assess the​ client's urine specific gravity. C. Measure abdominal girth weekly. D. Encourage fluid consumption. E. Weigh the client daily.

A, B, E ​Rationale: Ascites occurs because of portal hypertension and hypoalbuminemia. For the client with​ ascites, measures to counteract fluid volume overload should be taken. These measures include monitoring intake and​ output, assessing the urine specific gravity​ (an indicator of hydration​ status), and weighing the client daily. Abdominal girth should also be measured​ daily, not​ weekly, and the client should be placed on a fluid restriction.

The nurse is reviewing the laboratory results for a client suspected of having cirrhosis. Which result suggests to the nurse that the suspicion is​ correct? (Select all that​ apply.) A. Elevated serum ammonia levels B. Decreased sodium levels C. Increased albumin levels D. Decreased bilirubin levels E. Prolonged prothrombin time

A, B, E ​Rationale: In​ cirrhosis, prothrombin times are prolonged because the liver is unable to manufacture clotting factors. Serum ammonia levels are elevated because the liver lacks the ability to efficiently convert ammonia to ammonium for excretion as urea by the kidneys. Sodium levels are decreased because of hemodilution due to fluid retention. In​ cirrhosis, bilirubin levels are​ increased, and albumin levels are decreased.

Which assessment finding of a client diagnosed with cirrhosis should the nurse correlate with expected laboratory​ findings? (Select all that​ apply.) A. Peripheral edema B. Spider angiomas C. Confusion D. Frequent infections E. Bruising easily

A, C, D, E ​Rationale: Assessment findings that correlate with expected laboratory findings in the client with cirrhosis include bruising easily​ (coagulation studies), frequent infections​ (WBC count), peripheral edema​ (albumin levels), and confusion​ (ammonia levels). Although spider angiomas can be found in clients with​ cirrhosis, their presence is not associated with any laboratory testing.

A client diagnosed with cirrhosis of the liver states to the​ nurse, "This itching is driving me​ crazy." Which intervention is most appropriate for the nurse to​ implement? A. Apply an emollient lotion. B. Wash the​ client's skin with cool water and soap daily. C. Turn the client every 4 hours. D. Restrain the​ client's hands to prevent scratching.

A. Apply an emollient lotion. ​Rationale: As ammonia levels rise in​ cirrhosis, bile salt deposits are deposited on the​ skin, which causes pruritus. To maintain skin integrity and ease​ itching, the nurse should apply an emollient lotion to moisturize the skin and reduce itching.​ Warm, not​ cool, water should be​ used, and soap should be​ avoided, as hot water and soap dry out the skin and increase pruritus. To maintain skin​ integrity, the client should be turned every 2 hours. Restraints should always be a last option to prevent a client from causing​ self-harm. Mittens are a better option to prevent scratching.

The nurse is teaching a client how to prevent the development of cirrhosis. Which intervention should the nurse​ include? A. Avoid illegal drugs. B. Get a yearly flu shot. C. Cut down on the use of alcohol. D. Discontinue all medications.

A. Avoid illegal drugs. ​Rationale: Clients with diagnosed liver disease are at increased risk for cirrhosis. To prevent cirrhosis from​ occurring, clients should avoid illegal drugs. They should​ avoid, not just cut down​ on, all alcohol and continue taking all medications as prescribed. Flu shots are not known to prevent cirrhosis.

The nurse is creating a plan of care for a client diagnosed with cirrhosis who has experienced gastrointestinal bleeding. Which nursing intervention is most important for the nurse to perform for the​ client? A. Plan for consistent nursing care assignments. B. Monitor coagulation studies and platelet count. C. Apply mittens to the hands to prevent scratching. D. Teach the family the importance of maintaining diet restrictions.

B. Monitor coagulation studies and platelet count. Rationale: The nurse should take steps to minimize​ bleeding, which includes monitoring coagulation studies and platelet count. Blood in the intestinal tract is digested as a​ protein, which increases serum ammonia levels and the risk for hepatic encephalopathy. Consistent nursing care assignments help clients with impaired mental​ status; mittens help promote skin integrity in clients with​ pruritus; and maintaining diet restrictions help promote nutrition.​ However, these interventions are less urgent for the client who is at risk for bleeding.

A client suspected of having cirrhosis has prolonged prothrombin times. Which medication should the nurse expect to be​ prescribed? A. Vitamin B B. Vitamin K C. Nitrates D. Diuretics

B. Vitamin K ​Rationale: Prolonged prothrombin times indicate that the blood is taking longer to clot and the client is at risk for bleeding. Vitamin K is given to reduce the risk of bleeding. Diuretics are used to treat ascites. Nitrates are used along with a beta blocker to prevent rebleeding of esophageal varices. Vitamin B is not used for the treatment of cirrhosis.

The nurse is caring for a client diagnosed with hepatic encephalopathy. Which nursing action is most appropriate for this​ client? A. Administer medications to treat diarrhea. B. Provide a​ high-protein diet. C. Observe the client for asterixis. D. Avoid medications that stimulate the central nervous system.

C. Observe the client for asterixis. Rationale: The signs of early encephalopathy are sometimes subtle. It is important to identify neurologic changes early to begin treatment promptly. Asterixis​ (flapping of the​ hands) or changes in handwriting are early signs of neurologic impairment. The client should avoid medications that depress the central nervous system. A​ low-protein diet is prescribed to decrease nitrogenous waste products that accumulate in the blood and lead to hepatic encephalopathy. Regular bowel elimination promotes protein and ammonia​ elimination; therefore, measures should be taken to prevent constipation.

The nurse is caring for a client diagnosed with cirrhosis. The client asks the​ nurse, "Why does my skin itch so​ much?" How should the nurse​ respond? A. ​"Your skin itches because your protein levels are​ low." B. ​"Your skin itches because your fluid levels are​ low." C. ​"Your skin itches because your liver cannot eliminate bile​ salts." D. ​"Your skin itches because you have been bleeding​ internally."

C. ​"Your skin itches because your liver cannot eliminate bile​ salts." ​Rationale: In liver​ disease, the client becomes jaundiced with bile salts being deposited on the skin. This causes pruritus.​ Bleeding, low fluid​ levels, and low protein levels do not cause itching.

A client with a history of cirrhosis presents to the emergency department with bleeding esophageal varices. The healthcare provider inserts a Minnesota tube. Which assessment is most important for the nurse to make on the​ client? A. Monitor urine output. B. Monitor urine specific gravity. C. Auscultate bowel sounds. D. Auscultate breath sounds.

D. Auscultate breath sounds. ​Rationale: Following insertion of a Minnesota tube​ (a multiple lumen nasogastric tube with a gastric and esophageal​ balloon), it is a priority for the nurse to monitor the​ client's respiratory status. Balloon tamponade carries a number of​ risks, including​ aspiration, airway​ obstruction, and tissue ischemia and necrosis. Monitoring breath sounds will provide information about the​ client's respiratory status. Bowel​ sounds, urine specific​ gravity, and urine output are not affected by a Minnesota tube.