3d - Liver Failure, Hepatitis, Jaundice, Portal Hypertension, Ascites, Hepatic Encephalopathy, and Hepatic Cirrhosis

43. The client is diagnosed with cancer of the head of pancreas. Which s/s should the nurse expect to assess? 1. Clay-colored stools and dark urine. 2. Night sweats and fever. 3. Left lower abdominal cramps and tenesmus. 4. Nausea and coffee-ground emesis.

1. *The client will have jaundice, clay-colored stools, and tea-colored urine resulting from blockage of the bile drainage.* 2. Night sweats and fevers are associated with lymphoma. 3. Left lower abdominal cramps are associated with diverticulitis, and tenesmus is straining when deficating. 4. Nausea and coffee-ground emesis are symptoms of gastric ulcers.

27. The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse indicate in the plan of care? 1. Asses the abdomen for tympanic wave. 2. Monitor the client's blood pressure. 3. Percuss the liver for size and location. 4. Weigh the client twice each week.

*1. A client who has been diagnosed with portal hypertension should be assessed for a tympanic (fluid) wave to check for ascites.* 2. High blood pressure is not the etiology of portal hypertension. 3. In portal hypertension, percussion is difficult and will not provide pertinent information about the client's condition. 4. Weighing the client should be done daily, not twice each week.

27. The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care? 1. Assess the abdomen for tympanic wave. 2. Monitor the clients BP. 3. Percuss the liver for size and location. 4. Weigh the client twice each week.

*1. A client who has been diagnosed with portal hypertension should be assessed for a tympanic (fluid) wave to check for ascites.* 2. High blood pressure is not the etiology of portal hypertension. 3. In portal hypertension, percussion is difficult and will not provide pertinent information about the client's condition. 4. Weighing the client should be done daily, not twice each week.

82. The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is *at risk* for developing hepatic encephalopathy? 1. Gastrointestinal bleeding 2. Hypoalbuminemia 3. Splenomegaly 4. Hyperaldosteronism

*1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.* 2. Decreased albumin causes the client to develop ascites. 3. An enlarged spleen increases the rate at which red blood cells (RBCs), WBCs, and platelets are destroyed, causing the client to develop anemia, leukopenia, and thrombocytopenia, but not hepatic encephalopathy. 4. An increase in aldosterone causes sodium and water retention, resulting in the development of ascites and generalized edema.

90. The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? *Select all that apply.* 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

*1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers.* *2. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection.* *3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults.* 4. Immune globulin injections are administered as postexposure prophylaxis (after being exposed to hepatitis B), but encouraging these injections is not a health promotion activity. 5. Hepatotoxic medications should be avoided in clients who have hepatitis or who have had hepatitis. The health-care provider prescribes medications, and the layperson does not know which medications are hepatotoxic.

77. The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

*1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP.* 2. Applying emollient lotion will help prevent dry skin, which will help decrease pruritus; therefore, this would not require any intervention by the nurse. 3. Mittens will help prevent the client from scratching the skin and causing skin breakdown. This would not require intervention by the nurse. 4. The skin should be patted dry, not rubbed, because rubbing the skin will cause increased irritation. This action does not require intervention by the nurse.

92. The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

*1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily. * 2. TPN is not routinely prescribed for the client with hepatitis; the client must lose a large amount of weight and be unable to eat anything for TPN to be ordered. 3. Salt intake does not affect the healing of the liver. 4. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food intake.

86. The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

*1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop. * 2. Hepatitis B virus is spread through contact with infected blood and body fluids. 3. Hepatitis C virus is transmitted through infected blood and body fluids. 4. Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.

20. Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy? 1. Assess the client's neurological status. 2. Prepare to administer a loop diuretic. 3. Check the client's stool for blood. 4. Assess for an abdominal fluid wave.

*1. The increased serum ammonia level associated with liver failure causes the hepatic encephalopathy, which, in turn, leads to neurological deficit.* 2. Administering a loop diuretic is an appropriate intervention for ascites and portal hypertension. 3. Checking the stool for bleeding is an appropriate intervention for esophageal varices and decreased vitamin K. 4. Assessing the abdominal fluid wave is an appropriate intervention for ascites and portal hypertension.

79. 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. Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. * *2. Soft-bristle toothbrushes will help prevent bleeding of the gums.* *3. Platelet count, partial thromboplastin time/prothrombin time (PTT/PT), and international normalized ratio (INR) should be monitored to assess coagulation status.* *4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessary, the nurse should use small-gauge needles. * 5. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level not associate with vitamin K deficiency.

28. The nurse caring for the client diagnosed with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the HCP? 1. A decrease in clients weight of 1 pound. 2. An increase in urine output after administration of a diuretic. 3. An increase in abdominal girth of 2 inches. 4. A decrease in serum direct bilirubin to 0.6 mg/dL.

1. A decrease in weight indicated a loss in fluid and is not data necessary to report to the HCP. 2. An increase in urine output indicates the diuretic was effective. *3. An increase in abdominal girth indicates the ascites is increasing, meaning the client's condition is becoming more serious and should be reported to the HCP.* 4. The normal bilirubin value is 0.1 to 0.4 mg/dL; therefore, a decrease in the value, although is still elevated, would not be reported.

75. The public health hurse is discussing hepatitis with a client who is traveling to third world country in one month. Which recommendation should the nurse discuss with the cient? 1. A gamma globulin injection. 2. A hepatitis A vaccination. 3. A PPD skin test on the left arm. 4. A hep B vaccination.

1. A gamma globulin injection is administered to provide passive immunity to clients who have been exposed to hepatitis. *2. Hep A is contracted through the fecal-oral route of transmission; poor sanitary practices in third world countries place the client at risk for Hep A.* 3. This is a test to determine exposure to tuberculosis and does not have anything to do with hepatitis. 4. The Hep B vaccination administered for exposure to blood/body fluids, not through the fecal-oral route. This vaccination is not priority for individuals traveling to a third world country.

87. Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions 2. Standard Precautions 3. Droplet Precautions 4. Exposure Precautions

1. Airborne precautions are required for transmission occurring by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. *2. Standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.* 3. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with large-particle droplets generated during coughing, sneezing, talking, or suctioning. 4. Exposure precautions is not a designated isolation category.

29. The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom indicate the disease is progressing? 1. The client has a decrease in serum ammonia level. 2. The client is not able to circle choices on the menu. 3. The client is able to take deep breaths as directed. 4. The client is able to eat previously restricted food items.

1. An increase in serum ammonia levels is seen in clients diagnosed with hepatic encephalopathy and coma. *2. The inability to circle food items on the menu may indicate deterioration in the client's cognitive status. The client's neuro status is impaired w/hepatic encephalopathy; the nurse should investigate this behavior.* 3. The client being able to follow commands indicates the client's neuro status is intact. 4. Consuming foods providing adequate nutrition indicates the client is getting better and able to follow client teaching.

85. The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice 2. Normal appetite and pruritus 3. Being afebrile and left upper quadrant pain 4. Complaints of fatigue and diarrhea

1. Clay-colored stools and jaundice occur in the icteric phase of hepatitis. 2. Normal appetite and itching occur in the icteric phase of hepatitis. 3. Fever subsides in the icteric phase, and the pain is in the right upper quadrant. *4. "Flu-like" symptoms are the first complaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.*

88. The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the *most important* to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

1. Eating after each other should be discouraged, but is not the most important intervention. 2. Only bottled water should be consumed in third world countries, but this precaution is not necessary in American high schools. 3. Hepatitis B and C, not hepatitis A, are transmitted by sexual activity. *4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday songs takes approximately 30 seconds, which is how long an individual should wash his or her hands.*

80. Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting 2. Oligomenorrhea and decreased body hair 3. Clay-colored stools and hemorrhoids 4. Dyspnea and caput medusae

1. Hypoalbuminemia (decreased albumin) and muscle wasting are metabolic effects, not gastrointestinal effects. 2. Oligomenorrhea is no menses, which is a reproductive effect, and decreased body hair is an integumentary effect. *3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.* 4. Dyspnea is a respiratory effect, and caput medusae (dilated veins around the umbilicus) is an integumentary effect, although it is on the abdomen.

81. Which assessment question is *priority* for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years 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?"

1. It really doesn't matter how long the client has been drinking alcohol. The diagnosis of alcohol cirrhosis indicates the client has probably been drinking for many years. 2. An advance directive is important for he client who is terminally ill, but it is not the priority question. *3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol. * 4. This is not a typical question asked by the nurse unless the client is malnourished, which is not information provided in the stem.

75. The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

1. Sodium is restricted to reduce ascites and generalized edema, not for hepatic encephalopathy. 2. Fluids are calculated based in diuretic therapy, urine output, and serum electrolyte values; fluids do not affect hepatic encephalopathy. 3. A die high in calories and moderate in fat intake is recommended to promote healing *4. Ammonia is a by-product of protein metabolism and contributes to hepatic encepalopathy. Reducing protein intake should decrease ammonia levels*

89. Which instruction should the nurse discuss with the client who is in the *icteric* phase of hepatitis C? 1. Decrease alcohol intake 2. Encourage rest periods 3. Eat a large evening meal 4. Drink diet drinks and juices

1. The client mus avoid alcohol altogether, not decrease intake, to prevent further liver damage and promote healing. *2. Adequate rest is needed for maintaining optimal immune function.* 3. Clients are more often anorexic and nauseated in the afternoon and evening; therefore, the main meal should be in the morning. 4. Diet drinks and juices provide few calories, and the client needs and increased-calorie diet for healing.

95. Which statement by the client diagnosed with hepatitis *warrants immediate* intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

1. The client should avoid alcohol to prevent further liver damage and promote healing. 2. Rest is needed for healing of the liver and to promote optimum immune function. 3. Clients with hepatitis need increased caloric intake, so this is a good statement. *4. The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.*

74. The client has had a liver biopsy. Which *post-procedure* intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

1. The client should empty the bladder immediately prior to the liver biopsy, not after the procedure. 2. Foods and fluids are usually withheld two (2) hours after the biopsy, after which the client can resume the usual diet. *3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.* 4. Blood urea nitrogen (BUN) and creatinine levels are monitored for kidney function, not liver function, and the renal system is not affected with the liver biopsy.

73. The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (SengstakenBlakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

1. The client's throat is not anesthetized during the insertion of a nasogastric tube, so the gag reflex does not need to be assessed. *2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue. * 3. This laxative is administered to decrease the ammonia level, but the question does not sat the client's ammonia level is elevated. 4. Esophageal bleeding does not cause the ammonia level to be elevated.

96. Which task is *most appropriate* for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

1. The laboratory technician draws serum blood studies, not the UAP. 2. The UAP can obtain the intake and output, but the nurse must evaluate the data to determine if the results are normal for the client's disease process or condition. *3. The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed.* 4. The ward clerk has a specific training that allows the transcribing of the health-care provider orders.

93. 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.

1. The nurse must notify the infection control nurse as soon as possible so treatment can start if needed, but this is not the first intervention. *2. The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into skin.* 3. Postexposure prophylaxis may be needed, but this is not the first action. 4. The infection control/employee health nurse will check the status of the client whom the needle was used on before the nurse stuck herself.

76. The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

1. The procedure is done in the client's room, with the client seated either on the side of the bed or in a chair. 2. The client should empty the bladder prior to the procedure to avoid bladder puncture, but there is no need for an indwelling catheter to be inserted. *3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.* 4. The client does not have to hold the breath when the catheter is inserted into the peritoneum; this is done when obtaining a liver biopsy.

94. The client diagnosed with liver problems asks the nurse, "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

1. The serum ammonia level is increased in liver failure, but it is not the cause of clay-colored stools. *2. Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin.* 3. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but it does not affects the feces. 4. Vitamin deficiency, resulting from the liver's inability to detoxify vitamins, may cause steatorrhea, but it does not cause clay-colored stool.

73. Which data indicate to the nurse the client with end-stage liver failure is improving? 1. The client has a tympanic wave. 2. The client is able to perform asterixis. 3. The client is confused and lethargic. 4. The client's abdominal girth has decreased.

1. The tympanic wave indicates ascites, which is not an indicator of improving health. 2. Asterixis is a flapping of the hands, which indicates an elevated ammonia level. 3. Confusion and lethargy indicate increased ammonia level. *4. A decrease in the abdominal girth indicates an improvement in the ascitic fluid.*

21. Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B? 1. Explain the importance of good hand washing. 2. Recommend the client take the hepatitis B vaccine. 3. Tell the client not to ingest unsanitary food or water. 4. Discuss how to implement Standard Precautions.

1. This intervention would be appropriate for prevention of hepatitis A. *2. The hepatitis B vaccine will prevent the client from contracting this disease.* 3. This intervention would be appropriate for prevention of hepatitis A. 4. The nurse uses Standard Precautions, not the client.

83. The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's *best response*? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

1. This is a therapeutic response and is used to encourage the client to verbalize feelings but does not provide factual information. 2. This is passing the bucks; the nurse should be able to answer the question. *3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate foe the client.* 4. This is the medical explanation ad to why the medication dose is decreased, but it should not be used to explain to a layperson.

91. The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?" Which statement is the nurse's *best response*? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

1. This is a therapeutic response, and the nurse should provide factual information. *2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is as powerful oxidant and promotes liver cell growth.* 3. The nurse should not discourage complementary therapies. 4. This is a judgmental statement, and the nurse should encourage the client to ask questions.

78. 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 two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

1. Two (2) kg is more than four (4) pounds, which indicates severe fluid retention and is not an appropriate goal. *2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.* 3. Vital signs are appropriate to monitor, but they do not yield specific information about fluid volume status. 4.Having the client receive a low-sodium diet does not ensure the client will comply with the diet. The short-term goal must evaluate if the fluid volume is within normal limits.

84. The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client *needs more* teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

1. Two to three soft stools a day indicates the medication is effective. *2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.* 3. Diarrhea indicates and overdosage of the medication, possibly requiring the dosage to be decreased. The HCP needs to make this change in dosage, so the client understands the teaching. 4. The client should check the stool for bright-red blood as well as dark, tarry stools.