Advanced MedSurg EAQ #10 cirrhosis, hepatitis

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? 1 "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." 2 "I need to take good care of my belly and ankle skin where it is swollen." 3 "A scrotal support may be more comfortable when I have scrotal edema." 4 "I can use pillows to support my head to help me breathe when I am in bed."

1 If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency.

A patient with hepatitis A is in the acute phase. The nurse plans care while anticipating that the patient may be experiencing which symptoms? Select all that apply. 1 Fatigue 2 Pruritus 3 Anorexia 4 Dizziness 5 Visual disturbances

1, 2, 3 The acute phase of hepatitis usually lasts from one to four months. During the incubation period, symptoms may include malaise, anorexia and weight loss, fatigue, nausea, occasional vomiting, and abdominal (right upper quadrant) discomfort. The patient may find food repugnant, and smokers may have distaste for cigarettes. There is also a decreased sense of smell. Other symptoms may include headache, low-grade fever, arthralgias, and skin rashes. Pruritus (intense chronic itching) sometimes accompanies jaundice. The pruritus occurs as a result of the accumulation of bile salts beneath the skin. Dizziness and visual disturbances are not symptoms of the acute phase of hepatitis A.

A patient has just undergone a liver transplant and is now in the intensive care unit (ICU). What nursing interventions are appropriate for this patient to prevent respiratory complications? Select all that apply. 1 Encourage the patient to cough. 2 Consider repositioning the patient. 3 Instruct the patient to walk around the bed. 4 Encourage the patient to take deep breaths. 5 Administer cough suppressants to prevent coughing.

1, 2, 4 The patient who has had a liver transplant requires highly skilled nursing care in an ICU or another specialized unit. To prevent respiratory complications, the patient should be encouraged to use measures such as coughing, deep breathing, and repositioning. Administering cough suppressants would be counterproductive to recovery. The patient can be ambulated later, when the condition is stable.

A patient with cirrhosis of the liver is admitted to the hospital. What complications of cirrhosis is the nurse likely to find in the patient? Select all that apply. 1 Edema of the feet 2 Difficulty breathing 3 Disorientation and lethargy 4 Blood in the stools or black stools 5 Severe pain in the chest with a cold sweat

1, 3, 4 Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Gastric varices bleed easily. This bleeding can be presented as blood in vomiting or blood in the stool. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbances, and lethargy. Cirrhosis doesn't lead to pain in the chest with a cold sweat or difficulty in breathing.

What are the precautions that nurses and hospital staff should follow while handling patients suffering from hepatitis infections? Select all that apply. 1 The patient must be in a private room, and door should be closed. 2 Dispose of the needles and syringes used on the patient carefully. 3 Wear gloves while handling articles contaminated by urine or feces. 4 Always wear a mask, gown, and gloves when entering the patient's room. 5 Follow infection control precautions while injecting the patient, and avoid getting pricked by the used needle.

1, 3, 5 Hepatitis A spreads through the fecal-oral route, and hepatitis B spreads through blood. Hence the virus can spread through needles and syringes used by the patient. Also, the virus can spread while the nurse is handling the urine or fecal material of the patient; hence it is necessary to wear gloves. Hepatitis does not spread through air; hence a mask is not required. A private room is required in respiratory diseases, not in hepatitis.

The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching? 1 "I should take frequent rest periods." 2 "I can eat anything that appeals to me." 3 "I can do without my glass of wine with dinner." 4 "I should take only medications that have been prescribed."

2 Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use. In light of this, it is incorrect for the patient to say that he may eat anything. Patients with cirrhosis must also avoid alcohol. Frequent rest and limitation of medications to those that have been prescribed are appropriate resolutions in a newly diagnosed case of cirrhosis and therefore do not indicate the need for further teaching.

A female patient expresses her concern about becoming pregnant while her partner is on ribavirin therapy for chronic hepatitis C. What should the nurse advise the patient? 1 She can plan pregnancy now. 2 She should avoid getting pregnant now. 3 She should not get pregnant with this partner ever. 4 She should avoid any sexual intercourse after conception.

2 Any woman who is on ribavirin or whose male partner is on is on ribavirin should avoid pregnancy during treatment. The pregnancy can be planned after the treatment is complete. She can get pregnant with this partner, but not while on treatment. Avoiding intercourse after conception is not necessary.

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? 1 The patient has completed a college education. 2 The chest x-ray showed another lung cancer lesion. 3 The patient has been able to stop smoking cigarettes. 4 The patient has well controlled type 1 diabetes mellitus.

2 Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course. It does not matter if the patient has a college education. The fact that the patient has quit smoking is not a contraindication for liver transplant. The patient is a well-controlled diabetic, which is not a contraindication.

The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on what knowledge? 1 Decreased peristalsis in the gastrointestinal tract contributes to a buildup of bile salts. 2 Jaundice results from the body's inability to conjugate and excrete bilirubin. 3 A lack of clotting factors promotes the collection of blood under the skin surface. 4 Decreased colloidal oncotic pressure from hypoalbuminemia causes the yellowish skin discoloration.

2 Jaundice results from the functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth. Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubin. Jaundice is not caused by a build-up of bile salts, a lack of clotting factors, or decreased colloidal oncotic pressure.

A patient with cirrhosis of the liver is on furosemide. The nurse should monitor the patient for which findings to prevent complications of diuretic therapy? Select all that apply. 1 Lethargy 2 Tachycardia 3 Hypotension 4 Hypertension 5 Muscle weakness 6 Cardiac arrhythmias

2, 3, 5, 6 When a patient is on diuretic therapy, it is important to monitor fluid and electrolyte status. The patient should be monitored carefully for signs of hypokalemia, including tachycardia, hypotension, muscle weakness, and cardiac arrhythmias. Hypertension and lethargy are not complications of diuretic therapy.

The parent of a pediatric patient suffering from hepatitis A approaches the nurse and is worried about the spread of infection to other family members through use of the same bathroom. What should the nurse advise the patient's parent? Select all that apply. 1 Buy a separate commode for your son. 2 Clean the bathroom and commode thoroughly. 3 There is no need for concern; just use disposable toilet covers. 4 Ask your son to wash his hands thoroughly after using the bathroom. 5 Ask all other family members to wash their hands thoroughly before eating and after using the bathroom.

2, 4, 5 Hepatitis A spreads through the fecal-oral route. Transmission is prevented by maintaining hygiene. Proper hand washing is extremely important in preventing the spread of the virus. Buying a separate commode is unnecessary. Thorough cleaning of the bathroom and all the equipment is enough to limit spread of the virus. Use of disposable toilet sheets is not sufficient to prevent spread of the virus.

A patient with cancer that has metastasized to the liver manifests symptoms of fluid retention, including edema and ascites. To determine the effectiveness of the diuretic therapy that has been prescribed, what should the nurse assess? 1 Breath sounds 2 Bowel sounds 3 Abdominal girth 4 Recent blood work

3 Daily measurement of the abdominal girth provides a direct indication of ascitic fluid increase or decrease. Breath and bowel sounds are usually not affected by liver metastasis until the late stages, when fluid overload and multisystem organ involvement occur. Reviewing the results of the most recent blood work will not show direct measurement of the effectiveness of diuretic therapy.

A patient with hepatitis A asks whether other family members are at risk for "catching" the disease. The nurse's response will be based on the knowledge that hepatitis A is transmitted primarily in which way? 1 During sexual intercourse 2 By contact with infected body secretions 3 Through fecal contamination of food or water 4 Through kissing that involves contact with mucous membranes

3 Hepatitis A is primarily transmitted through ingestion of organisms on fecally contaminated hands, food, or water. Care should be taken in the handling of food and water, as well as contaminated items such as bed linens, bedpans, and toilets. Hand hygiene and personal protective equipment such as gloves are important in preventing the spread of infection for hospital personnel. In the home, hand hygiene and good personal hygiene are important in decreasing the risk of transmission. Sexual intercourse, contact with infected body secretions, and contact through mucous membranes all present higher risk for hepatitis B and C than for hepatitis A.

A patient has been admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse. Laboratory results are significant for an alanine aminotransferase (ALT) of 198 IU/L and aspartate transaminase (AST) of 224 IU/L. Which diagnosis does the nurse attribute these findings to? 1 Malnutrition 2 Osteomyelitis 3 Alcohol abuse 4 Diabetes mellitus

3 In the patient with alcohol abuse, liver disease could develop as a complication, increasing the liver function tests above the normal levels. The normal ALT range is 7 to 56 IU/L, and the normal AST range is 5 to 40 IU/L. Diabetes would result in elevated blood sugar levels. Malnutrition would be evidenced by low protein levels. Osteomyelitis is an infection of the bone, which would result in an elevated white blood cell count.

The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? 1 Cardiac output 2 Blood pressure 3 Abdominal girth 4 Intake and output

3 Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the health care provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continue to be monitored to account for the paracentesis fluid, but these are not as informative as abdominal girth.

A patient with hepatitis A infection is being discharged from the hospital. What is the most important instruction that the nurse should include in the discharge teaching? 1 Do not share razors or toothbrushes. 2 Isolate the patient from other family members. 3 Wash hands carefully after bowel movements. 4 Take acetaminophen every four hours if fever persists.

3 The mode of transmission of hepatitis A infection is the fecal-oral route. Therefore it is very important to maintain personal and environmental hygiene. The nurse should teach the patient and the family members about careful hand washing immediately after bowel movements and before eating to prevent outbreaks of hepatitis A viral infection. Not sharing toothbrushes and razors is a concern for the prevention of hepatitis B and C, because they are transferred through blood contact. There is no need to isolate the patient with hepatitis A unless he or she is incontinent or maintains poor personal hygiene. Acetaminophen may cause liver damage and should be avoided in hepatic viral infection.

A nurse is caring for a patient with cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination? Select all that apply. 1 White patches on skin 2 Deposits of dark pigments 3 Small areas of bleeding into the skin 4 Vascular lesions formed by small blood vessels 5 Small dilated blood vessels with spiderlike branches

3, 4, 5 Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis.

A patient with acute hepatitis B will be discharged tomorrow. The nurse should include which measures in the discharge teaching plan? Select all that apply. 1 Restrict fluid intake. 2 Avoid alcohol for the first three weeks. 3 Avoid foods that are very hot or very cold. 4 Be sure to allow for periods of rest during the day. 5 Participate in an exercise regimen to build stamina. 6 Eat small meals frequently rather than three times a day.

3, 4, 6 Several measures are important for ensuring that the patient with hepatitis receives adequate nutrition. The anorexia and distaste for food cause nutritional problems. Assess the patient's tolerance of specific foods and eating patterns. Small, frequent meals may be preferable to three large ones and also may help prevent nausea. Measures to stimulate the appetite, such as mouth care, antiemetics, and attractively served meals in pleasant surroundings, should be included in the nursing care plan. Drinking carbonated beverages and avoiding very hot or very cold foods may help alleviate anorexia. Rest is an important factor in promoting hepatocyte regeneration. Assess the patient's response to the rest and activity plan, and modify it accordingly. Adequate fluid intake (2500 to 3000 mL/day) is important. Restricting fluid intake and participating in exercise regimens are not appropriate measures. Patients with hepatitis need to avoid alcoholic beverages.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? 1 "The hepatitis vaccine will provide immunity from this exposure and future exposures." 2 "I am afraid there is nothing you can do because the patient was infectious before admission." 3 "You will need to be tested first to make sure you don't have the virus before we can treat you." 4 "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

4 Immunoglobulin provides temporary (one to two months) passive immunity and is effective for preventing hepatitis A if given within two weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is used only for pre-exposure prophylaxis.

A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? 1 Decrease fluid intake to avoid ascites. 2 Eat foods quickly so they do not get cold and cause distress. 3 Avoid exercise because it may cause bleeding of the varices. 4 Avoid straining during defecation to keep venous pressure low

4 Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid, and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation.

When teaching the male patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? 1 "I will need to take adefovir to prevent chronic HCV." 2 "I will use care when kissing my wife to prevent giving it to her." 3 "Now that I have had HCV, I will have immunity and not get it again." 4 "I will need to be checked for chronic HCV and other liver problems."

4 The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with hepatitis A virus (HAV) and HBV, so the patient may be reinfected with another type of HCV.