49 chapter - exam 1

A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has? Hemolytic jaundice Hepatocellular jaundice Obstructive jaundice Cirrhosis of the liver

Obstructive jaundice Explanation: Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.

A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate? On the left side Trendelenburg On the right side High Fowler's

On the right side Explanation: In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the patient on his left side is not indicated. Positioning the patient in the Trendelenburg position may be indicated if the patient is in shock, but is not the position designed for the patient after liver biopsy. High Fowler's position is not indicated for the patient after liver biopsy.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as? Constructional apraxia Fetor hepaticus Ataxia Asterixis

Asterixis Explanation: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13

A nurse is teaching a patient about the types of chronic liver disease. The patient's teaching is determined to be effective based on the correct identification of which of the following types of cirrhosis caused by scar tissue surrounding the portal areas? Alcoholic cirrhosis Postnecrotic cirrhosis Biliary cirrhosis Compensated cirrhosis

Alcoholic cirrhosis Explanation: Alcoholic cirrhosis, in which the scar tissue characteristically surrounds the portal areas, is most frequently caused by chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? Hemolytic Hepatocellular Obstructive Nonobstructive

Hemolytic Explanation: Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? Hepatic encephalopathy Portal hypertension Asterixis Cirrhosis

Hepatic encephalopathy Explanation: Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? Respiratory assessment related to increased thoracic pressure Urinary output related to increased sodium retention Peripheral vascular assessment related to immobility Skin assessment related to increase in bile salts

Respiratory assessment related to increased thoracic pressure Explanation: If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered? Chenodiol Ursodiol Tacrolimus Interferon alfa-2b, recombinant

Tacrolimus Explanation: In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus or cyclosporine are two immunosuppresants that may be used. Chenodiol and ursodiol are agents used to dissolve gall stones. Recombinant interferon alfa-2b is used to treat chronic hepatitis B, C, and D to force the virus into remission.

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone (Aldactone) Vasopressin (Pitressin) Nitroglycerin Cimetidine (Tagamet)

Vasopressin (Pitressin) Explanation: Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. The nurse understands that a likely cause of her symptoms is ________. acute cholecystitis hepatitis A hepatitis B pancreatitis

acute cholecystitis Explanation: Gallstones are more frequent in women, particularly women who are middle-aged and obese. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain that may radiate to the back and shoulders. The patient profile and symptoms are suggestive of acute cholecystitis.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? Creatinine Urobilinogen Chloride Albumin

Albumin Explanation: Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? Decompression Instillation Gavage Lavage

Decompression Explanation: Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. This is not the most common purpose of a nasogastric tube after surgery; instillations in a nasogastric tube after surgery are done when necessary to promote patency. This is contraindicated after abdominal surgery until peristalsis returns. This is not the most common purpose of a nasogastric tube after surgery; lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: severe abdominal pain radiating to the shoulder. anorexia, nausea, and vomiting. eructation and constipation. abdominal ascites.

anorexia, nausea, and vomiting. Explanation: Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? Hemolytic Hepatocellular Obstructive Nonobstructive

Hemolytic

nurse is responsible for monitoring the diet of a patient with hepatic encephalopathy. The nurse knows that the 185-pound male should have a daily protein intake between __________. 17 and 50 grams 25 and 75 grams 34 and 100 grams 42 and 126 grams

42 and 126 grams Daily protein intake should be limited to 0.5 to 1.5 g/kg. Therefore, a person who weighs 185 lbs weighs 84 kg. To calculate protein intake, multiply the 84 kg by the low and high ranges: (84 kg × 0.5 = 42 g; 84 kg × 1.5 = 126 g). This patient would require a daily protein range from 42 to 126 g.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? Yellow-green Black and tarry Blood tinged Clay-colored or whitish

Clay-colored or whitish Explanation: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? Assessment of oral cavity for foul-smelling breath Daily weight and measurement of abdominal girth Auscultation of abdomen Palpation of abdomen for a fluid shift

Daily weight and measurement of abdominal girth Explanation: Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis

cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? Straw-colored urine Reduced hematocrit Clay-colored stools Elevated urobilinogen in the urine

Clay-colored stools Explanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? Colonoscopy Abdominal x-ray Cholecystectomy Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) Explanation: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.

The mode of transmission of hepatitis A virus (HAV) includes which of the following? Fecal-oral Blood Semen Saliva

Fecal-oral Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? Hepatic encephalopathy Esophageal varices Hepatitis C Portal hypertension

Hepatic encephalopathy Explanation: The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? Hepatitis B is transmitted primarily by the oral-fecal route. Hepatitis A is frequently spread by sexual contact. Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis G is similar to hepatitis A.

Hepatitis C increases a person's risk for liver cancer. Explanation: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? Polyuria Bradycardia Hypotension Warm moist skin

Hypotension Explanation: Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

Which of the following symptoms would indicate that a client with chronic pancreatitis has developed secondary diabetes? Increased appetite and thirst Vomiting and diarrhea Low blood pressure and pulse Decreased urination and constipation

Increased appetite and thirst Explanation: When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.

The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? Spironolactone (Aldactone) Cholestyramine (Questran) Lactulose (Cephulac) Kanamycin (Kantrex)

Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Serum potassium level of 3.5 mEq/L Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Blood pH of 7.25

Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

Which of the following is the recommended dietary treatment for a client with chronic cholecystitis? Low-fat diet High-fiber diet Low-residue diet Low-protein diet

Low-fat diet Explanation: The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications. A low-fat diet is recommended because a malfunctioning gallbladder will not secrete sufficient bile to breakdown dietary fats.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. Which of the following is an important education topic regarding ingestion of medications? Metabolism of medications The need for increased drug dosages The need for more frequently divided doses Medications will no longer be effective in clients with liver disease.

Metabolism of medications Explanation: Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: The digestion of dietary and blood proteins. Excessive diuresis and dehydration. Severe infections and high fevers. Excess potassium loss subsequent to prolonged use of diuretics.

The digestion of dietary and blood proteins. Explanation: Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client? Vasopressin (Pitressin) Spironolactone (Aldactone) Propranolol (Inderal) Lactulose (Cephulac)

Vasopressin (Pitressin) Explanation: In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

x Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone (Aldactone) Vasopressin (Pitressin) Nitroglycerin Cimetidine (Tagamet)

Vasopressin (Pitressin) Explanation: Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? Vitamin A Thiamine Riboflavin Vitamin K

Vitamin A Explanation: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? Potassium Vitamin K Vitamin B Oral bile acids

Vitamin K Explanation: Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis? Such clients cannot tolerate high-glucose concentration. Such clients are at risk for gallbladder contraction. Such clients are at risk for hepatic encephalopathy. Such clients can digest high-fat foods.

such clients cannot tolerate high-glucose concentration. Explanation: Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.