ATI Cirrhosis

A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? A. Alcohol B. Caffeine C. Cocaine D. Inhalants

A. Alcohol Rationale: Chronic alcohol use disorder is one of the primary causes of cirrhosis of the liver.

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A. Decrease the client's fluid intake. B. Increase the client's saturated fat intake. C. Increase the client's sodium intake. D. Decrease the client's carbohydrate intake.

A. Decrease the client's fluid intake. Rationale: The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

A nurse is reviewing the laboratory results of a client who has liver failure with ascites and is receiving spironolactone. Which of the following findings should the nurse expect? A. Decreased sodium level B. Decreased phosphate level C. Decreased potassium level D. Decreased chloride level

A. Decreased sodium level Rationale: The nurse should expect a decreased sodium level. Spironolactone is a potassium-sparing diuretic that inhibits the action of aldosterone, resulting in an increased excretion of sodium.

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect? A. Petechiae B. Hypertension C. Osteoarthritis D. Peripheral ulcers

A. Petechiae Rationale:A manifestation of advanced cirrhosis is petechiae due to impaired coagulation from a dysfunctional liver.

A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? A. Provide a high carbohydrate diet. B. Administer acetaminophen for pain. C. Encourage eating three large meals daily. D. Include high protein snacks.

A. Provide a high carbohydrate diet. Rationale: A client with hepatitis should have a diet high in carbohydrates due to altered nutrient metabolism.

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take? A. Teach the parents about cortisol replacement therapy. B. Place the child on a low-sodium diet. C. Monitor the child for fluid volume excess. D. Discuss the manifestations of hyperglycemia with the parents.

A. Teach the parents about cortisol replacement therapy. Rationale: The nurse should plan to teach the child's parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? A. Vitamin K B. Heparin C. Warfarin D. Ferrous sulfate

A. Vitamin K Rationale:A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver; therefore, the nurse should plan to administer vitamin k.

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? A. Avoid covering sores with bandages. B. Avoid handwashing after eating. C. Avoid foods prepared with tap water. D. Avoid eating meat.

C. Avoid foods prepared with tap water. Rationale: To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? A. "It is caused by the lack of production of insulin by the pancreas." B. "It is caused by the lack of production of aldosterone by the adrenal gland." C. "It is caused by the overproduction of growth hormone by the pituitary gland." D. "It is caused by the overproduction of parathormone by the parathyroid gland."

B. "It is caused by the lack of production of aldosterone by the adrenal gland." Rationale: Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland.

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C? A. A client who eats raw shellfish B. A client who has multiple tattoos C. A client who works in a child care center D. A client who has recently traveled to an underdeveloped country

B. A client who has multiple tattoos Rationale: Hepatitis C is transmitted via blood-to-blood contact. The nurse should recognize that improperly maintained tattoo equipment may aid in transmission and could increase the client's risk for contracting hepatitis C.

A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? A. Hyperglycemia B. Adrenocortical insufficiency C. Severe dehydration D. Rebound pulmonary congestion

B. Adrenocortical insufficiency Rationale: Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.

A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? A. Glucose B. Ammonia C. Potassium D. Bicarbonate

B. Ammonia Rationale: Lactulose, a disaccharide, is a sugar that works as an osmotic diuretic. It prevents absorption of ammonia in the colon. Accumulation of ammonia in the bloodstream, which occurs in pathologic conditions of the liver, such as cirrhosis, may affect the central nervous system, causing hepatic encephalopathy or coma.

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A. Elevate the client's feet. B. Increase the client's IV fluid rate. C. Initiate a dopamine IV infusion for the client. D. Administer a unit of packed RBCs.

B. Increase the client's IV fluid rate. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to increase the client's IV fluid rate. Providing fluid to the client will restore circulating volume and increase blood pressure.

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH? A. Osteoarthritis B. Lung cancer C. Liver cirrhosis D. Dyspepsia

B. Lung cancer Rationale: The nurse should ask the client if he has a history of lung cancer because some of the treatment options for small cell lung cancer can cause secretion of antidiuretic hormone. This results in the body retaining water and can cause the syndrome of inappropriate antidiuretic hormone (SIADH).

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform? A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis. B. Maintain constant observation while the balloons are inflated. C. Suction the tube every 2 hr and as needed to maintain patency. D. Keep the head of the bed flat at all times to prevent the development of shock.

B. Maintain constant observation while the balloons are inflated. Rationale: A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. When the balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction.

A nurse is assessing four clients on a medical unit. The nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism? A. A client who has a butterfly rash on his face. B. Moon face C. A client who has a positive Chvostek's sign. D. A client who has muscle hypertrophy.

B. Moon face Rationale: A client who has a moon face and fat pads on his neck, back and shoulders is exhibiting manifestations of hypercortisolism or Cushing's syndrome.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate? A. Maintain an IV of 0.45% sodium chloride. B. Restrict fluid intake to 1,000 mL per day. C. Provide a diet containing 2 g of sodium per day. D. Administer desmopressin acetate 0.2 mg orally.

B. Restrict fluid intake to 1,000 mL per day. Rationale: Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood. The nurse should offer this client frequent oral care to prevent discomfort and breakdown of the oral mucosa.

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client? A. Moist skin B. Spider angiomas C. Tarry stools D. Blood in the urine

B. Spider angiomas Rationale:Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web. This is an expected finding for a client who has cirrhosis.

A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. Which of the following manifestations indicates an adverse effect of the medication? A. Dry mouth B. Vomiting C. Headache D. Peripheral edema

B. Vomiting Rationale: The nurse will monitor for vomiting as an adverse effect of lactulose.

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take? A. Provide a low-carbohydrate diet. B. Weigh the client daily. C. Administer oral corticosteroids. D. Restrict fluid intake.

B. Weigh the client daily. Rationale: Addison's disease is an endocrine disorder that causes weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin.

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client? A. Baked potato B. Stewed tomatoes C. Ham sandwich D. Milkshake

C. Ham sandwich Rationale: Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma albumin and are placed on low-sodium diets.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A. A family history increases your risk for acquiring hepatitis A. B. Hepatitis A infects the kidneys. C. Manifestations of the virus are similar to flu-like symptoms. D. The incubation of the virus is 5 days.

C. Manifestations of the virus are similar to flu-like symptoms. Rationale: The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A. Avoid eating at fast food restaurants. B. Avoid serving raw foods. C. Practice effective hand hygiene. D. Wear barrier protection during vaginal intercourse.

C. Practice effective hand hygiene. Rationale: Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? A. Administer diuretics. B. Restrict the client's intake of fluids. C. Reduce the client's intake of protein D. Administer vitamin K.

C. Reduce the client's intake of protein. Rationale: Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? A. You may donate blood 6 months after completing the medication regimen. B. Consume a high-protein diet. C. Rest frequently throughout the day. D. Take acetaminophen every 4 hr, as needed, for discomfort

C. Rest frequently throughout the day. Rationale: Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic

A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions? A. Malnutrition B. Hepatitis A C. Diabetes D. Cirrhosis

D. Cirrhosis Rationale: The nurse should recognizes this client is displaying manifestations of cirrhosis. A history of alcohol use disorder increases the client's risk of developing cirrhosis and coagulation defects are a common complication of cirrhosis.

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan? A. Administer antibiotics. B. Provide a diet high in fat. C. Restrict fluids. D. Encourage short periods of ambulation.

D. Encourage short periods of ambulation. Rationale: The nurse should encourage a client who has hepatitis B to alternate between activity and rest.

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? A. Weight loss B. Hypotension C. Diaphoresis D. Hyperpigmentation

D. Hyperpigmentation Rationale: Hyperpigmentation, bruising, and striae or stretch marks, are manifestations of Cushing's syndrome.

A nurse is teaching a client about the causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching? A. Excessive alcohol consumption B. Hepatitis C C. Hepatotoxic medications D. Obstruction of the bile duct

D. Obstruction of the bile duct Rationale: Prolonged obstruction of the common bile duct is the most common cause of biliary cirrhosis.

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.) A. Administer furosemide. B. Administer warfarin. C. Implement a low-sodium diet. D. Measure the client's abdominal girth. E. Encourage weightlifting during physical therapy.

Rationale: Administer furosemide is correct. The nurse should administer furosemide to the client to reduce fluid accumulation in the abdomen. Administer warfarin is incorrect. The nurse should avoid administering warfarin to the client due to possible destruction of platelets caused by splenomegaly, which can result in spontaneous bleeding.Propranolol is prescribed instead to discourage bleeding. Implement a low-sodium diet is correct. The nurse should implement a low-sodium diet to control fluid accumulation in the abdomen. Measure the client's abdominal girth is correct. The nurse should measure the client's abdominal girth. Daily weights are an even more reliable indicator of fluid accumulation. Encourage weight lifting during physical therapy is incorrect. The nurse should understand weight lifting can cause bleeding.