Ch 43: Assessment and Management of Patients with Hepatic Disorders

b) Reduce fluid accumulation and venous pressure Pg. 1377 Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

32. A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a) Promote optimal neurologic function b) Reduce fluid accumulation and venous pressure c) Treat the esophageal varices d) Cure the cirrhosis

c) Low-fat diet Pg. 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.

39. What is the recommended dietary treatment for a client with chronic cholecystitis? a) Low-protein diet b) High-fiber diet c) Low-fat diet d) Low-residue diet

d) Ultrasound of liver and abdomen Pg. 1370 Ultrasonography of the liver and abdomen will definitively confirm the presence of ascites. An abdominal x-ray, colonoscopy, and computed tomography of the abdomen would not confirm the presence of ascites.

40. Which of the following diagnostic studies definitely confirms the presence of ascites? a) Colonoscopy b) Computed tomography of abdomen c) Abdominal x-ray d) Ultrasound of liver and abdomen

a) 1 drink Pg. 1395 Current guidelines from the CDC and the Dietary Guidelines for Americans define moderate alcohol consumption as up to one drink per day for women and up to two drinks per day for men. Current guidelines from the Canadian Centre on Substance Use and Addiction are up to 10 drinks per week with no more than 2 drinks per day for women and up to 15 drinks per week with no more than 3 drinks per day for men. A drink is commonly defined as 12 ounces of 5% alcohol content beer or cider, 5 ounces of wine, and 1.5 ounces of 80 proof distilled alcohol.

10. Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of health teaching, the nurse advises a group of women that the amount of daily alcohol use should generally be limited to the equivalent of: a) 1 drink b) 2 drinks c) 3 drinks d) 4 drinks

c) Fecal-oral Pg. 1385 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.

56. The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Saliva c) Fecal-oral d) Blood

d) High-dose corticosteroids Pg. 1392 Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis would be used to withdraw fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.

45. A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? a) Paracentesis b) Azathioprine c) Liver transplantation d) High-dose corticosteroids

d) Electrocardiogram changes Pg. 1377 Vasopressin (Pitressin) is administered during the management of an urgent situation with an acute esophageal bleed because of its vasoconstrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose clients with coronary artery disease to cardiac ischemia; therefore, the nurse observes the client for evidence of chest pain, ECG changes, and vital sign changes. Vasopressin will does not infer with urinary output, electrolytes, or liver enzymes.

71. A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration? a) Urinary output changes b) Electrolytes level changes c) Liver enzyme changes d) Electrocardiogram changes

b) Albumin infusion Pg. 1374 Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of postparacentesis circulatory dysfunction with renal dysfunction, hyponatremia, and rapid reaccumulation of ascites associated with decreased effective arterial volume.

52. What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention? a) Diuretic therapy b) Albumin infusion c) Therapeutic paracentesis d) Platelet infusions

b) Elevated alpha-fetoprotein Pg. 1405 Alpha-fetoprotein, a serum protein normally produced during fetal development, is a marker that, if elevated, can induce a primary malignant liver tumor. Total bilirubin and serum enzyme levels may be elevated. White blood cell count elevation would indicate an inflammatory response.

70. A client is seeing the physician for a suspected tumor of the liver. What laboratory study results would indicate that the client may have a primary malignant liver tumor? a) Elevated white blood cell count b) Elevated alpha-fetoprotein c) Decreased alkaline phosphatase levels d) Decreased AST levels

b) Lactulose Pg. 1382 Lactulose 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 are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

29. The nurse is administering medications to a client 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? a) Kanamycin b) Lactulose c) Spironolactone d) Cholestyramine

b) Spironolactone (Aldactone) Pg. 1395 Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

4. The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? a) Acetazolamide (Diamox) b) Spironolactone (Aldactone) c) Bumetanide (Bumex) d) Furosemide (Lasix)

d) Octreotide Pg. 1377 Acute hemorrhage from esophageal varices is life threatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide is started as soon as possible. Octreotide is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.

34. A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding? a) Epinephrine b) Vasopressin c) Vitamin K d) Octreotide

a) Increased abdominal girth b) Rapid weight gain d) Stretch marks e) Visible distended veins Pg. 1373 The presence and extent of ascites are assessed by percussion of the abdomen. When fluid has accumulated in the peritoneal cavity, the flanks bulge when the patient assumes a supine position. Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall. Foul-smelling breath is not a clinical manifestation of ascites.

58. What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply. a) Increased abdominal girth b) Rapid weight gain c) Foul-smelling breath d) Stretch marks e) Visible distended veins

b) Vitamin A Pg. 1384 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.

7. 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? a) Thiamine b) Vitamin A c) Riboflavin d) Vitamin K

c) Hepatic encephalopathy Pg. 1381 Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces 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.

5. A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? a) Portal hypertension b) Cirrhosis c) Hepatic encephalopathy d) Asterixis

a) Maintaining the airway Pg. 1377 Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

54. A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? a) Maintaining the airway b) Maintaining fluid volume c) Relieving the client's anxiety d) Controlling bleeding

b) Clay-colored or whitish Pg. 1388-1389 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 indicators of obstructive jaundice but may indicate other GI tract disorders.

27. The nurse is assessing a client with cirrhosis of the liver. Which stool characteristic would the nurse expect the client to report? a) Black and tarry b) Clay-colored or whitish c) Yellow-green d) Blood tinged

b) Ecchymoses c) Petechiae d) Jaundice Pg. 1368 The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

36. While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the likelihood of liver problems? Select all that apply. a) Cyanosis of the lips b) Ecchymoses c) Petechiae d) Jaundice e) Aphthous stomatitis

d) Right lateral decubitus position Pg. 1369 After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.

46. After undergoing a liver biopsy, a client should be placed in which position? a) Supine position b) Semi-Fowler's position c) Prone position d) Right lateral decubitus position

a) Hemolytic Pg. 1371 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 clients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive and hepatocellular jaundice are the result of liver disease. Nonobstructive jaundice occurs with hepatitis.

55. The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction? a) Hemolytic b) Hepatocellular c) Obstructive d) Nonobstructive

c) Loss of 2.2 lb (1 kg) in 24 hours Pg. 1373 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.

63. 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? a) Serum potassium level of 3.5 mEq/L b) Blood pH of 7.25 c) Loss of 2.2 lb (1 kg) in 24 hours d) Serum sodium level of 135 mEq/L

b) On the right side Pg. 1369 Immediately after the biopsy, assist the client to turn on to the right side; place a pillow under the costal margin, and caution the client to remain in this position. 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 client on the left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but it is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

12. A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position? a) On the left side b) On the right side c) Trendelenburg d) High Fowler

b) Subnormal serum glucose and elevated serum ammonia levels Pg. 1400-1402 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.

14. 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: a) Subnormal clotting factors and platelet count b) Subnormal serum glucose and elevated serum ammonia levels c) Elevated blood urea nitrogen and creatinine levels and hyperglycemia d) Elevated liver enzymes and low serum protein level

b) Liver resection Pg. 1406 Surgical resection is the treatment of choice when liver cancer is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. The use of external-beam radiation for the treatment of liver tumors has been limited by the radiosensitivity of normal hepatocytes and the risk of destruction of normal liver parenchyma. Studies of clients with advanced cases of liver cancer have shown that the use of systemic chemotherapeutic agents leads to poor outcomes. Laser hyperthermia has been used to treat hepatic metastases.

15. A client with right upper quadrant pain and weight loss is diagnosed with liver cancer. For which treatment will the nurse prepare the client when it is determined that the disease is confined to one lobe of the liver? a) Laser hyperthermia b) Liver resection c) Radiation d) Chemotherapy

d) Asterixis Pg. 1381 Hepatic encephalopathy is manifested by numerous central nervous system effects including disorientation, confusion, mood swings, reversed day-night sleep patterns with sleep occurring during the day, agitation, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy. As hepatic encephalopathy becomes more severe, the client becomes stuporous and eventually comatose.

17. Which of the following would the nurse expect to assess in a conscious client with hepatic encephalopathy? a) Negative Babinski reflex b) Increased motor activity c) Little desire to sleep d) Asterixis

a) "You may have eaten contaminated restaurant food" Pg. 1385 Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

18. A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? a) "You may have eaten contaminated restaurant food" b) "You could have gotten it by using I.V. drugs" c) "You probably got it by engaging in unprotected sex" d) "You must have received an infected blood transfusion"

b) Hemolytic Pg. 1371 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 clients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive and hepatocellular jaundice are the result of liver disease. Nonobstructive jaundice occurs with hepatitis.

19. The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction? a) Nonobstructive b) Hemolytic c) Obstructive d) Hepatocellular

a) The client's hepatic function is decreasing Pg. 1381 The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

2. A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client's hepatic function is decreasing b) The client is avoiding the nurse c) The client didn't take his morning dose of lactulose (Cephulac) d) The client is relaxed and not in pain

b) Ascites c) Enlarged liver size e) Hemorrhoids Pg. 1368 Early in the course of cirrhosis, the liver tends to be large, and the cells are loaded with fat. The liver is firm and has a sharp edge that is noticeable on palpation. Portal obstruction and ascites, late manifestations of cirrhosis, are caused partly by chronic failure of liver function and partly by obstruction of the portal circulation. The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and shunting of blood from the portal vessels into blood vessels with lower pressures. These distended blood vessels form varices or hemorrhoids, depending on their location. Because of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, and K), signs of deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Additional clinical manifestations include deterioration of mental and cognitive function with impending hepatic encephalopathy and hepatic coma, as previously described.

20. A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. a) Accelerated behaviors and mental processes b) Ascites c) Enlarged liver size d) Excess storage of vitamin C e) Hemorrhoids

c) Clay-colored stools Pg. 1371-1372 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.

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

d) Cirrhosis Pg. 1394 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.

22. 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: a) Peptic ulcer disease b) Cholelithiasis c) Appendicitis d) Cirrhosis

a) Measure abdominal girth according to a set routine Pg. 1404 If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

23. When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a) Measure abdominal girth according to a set routine b) Report the condition to the physician immediately c) Provide the client with nonprescription laxatives d) Ask the client about food intake

a) Acetaminophen Pg. 1392 Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.

26. An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: a) Acetaminophen b) Ibuprofen c) Dextromethorphan d) Benadryl

d) Spironolactone Pg. 1373 The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion). Acetazolamide and ammonium chloride are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.

30. A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? a) Ammonium chloride b) Acetazolamide c) Furosemide d) Spironolactone

d) Portal hypertension Pg. 1375 Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

31. Which is the most common cause of esophageal varices? a) Jaundice b) Asterixis c) Ascites d) Portal hypertension

b) Albumin Pg. 1372-1373 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.

33. 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? a) Chloride b) Albumin c) Creatinine d) Urobilinogen

a) The digestion of dietary and blood proteins Pg. 1381 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 (i.e., bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

35. 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: a) The digestion of dietary and blood proteins b) Severe infections and high fevers c) Excessive diuresis and dehydration d) Excess potassium loss subsequent to prolonged use of diuretics

c) Liver transplantation Pg. 1392 Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

38. A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the client has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this client is what? a) Lobectomy b) Transfusion of packed red blood cells and fresh-frozen plasma (FFP) c) Liver transplantation d) IV administration of immune globulins

b) Daily measurement of weight and abdominal girth Pg. 1373 Measuring and recording of abdominal girth and body weight daily are essential to assess the progression of ascites and its response to treatment.

41. Which nursing assessment is most important in a client diagnosed with ascites? a) Assessment of the oral cavity for foul-smelling breath b) Daily measurement of weight and abdominal girth c) Palpation of abdomen for a fluid shift d) Auscultation of abdomen

a) Octreotide Pg. 1377 In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Octreotide (Sandostatin) causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage. 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.

42. A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client? a) Octreotide b) Spironolactone c) Propranolol d) Lactulose

b) Tachycardia and tachypnea Pg. 1376 The compensatory stage is the first stage of shock. During this stage, the sympathetic nervous system (SNS) is activated due to changes in blood volume and blood pressure. The SNS stimulates the cardiovascular system, causing tachycardia, and the respiratory system, causing tachypnea. Thus, tachycardia (not bradycardia) and tachypnea (not bradypnea) occur with the compensatory stage of shock.

43. A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? a) Tachycardia and bradypnea b) Tachycardia and tachypnea c) Bradycardia and bradypnea d) Bradycardia and tachypnea

a) Glucose metabolism c) Ammonia conversion d) Protein metabolism Pg. 1366 Functions of the liver include the metabolism of glucose, protein, fat, and drugs; conversion of ammonia; storage of vitamins and iron; formation of bile; and excretion of bilirubin. The liver is not responsible for the metabolism of carbohydrates or the storage of zinc.

44. A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply. a) Glucose metabolism b) Zinc storage c) Ammonia conversion d) Protein metabolism e) Carbohydrate metabolism

a) Ineffective breathing pattern Pg. 1401 In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the respiratory rate and low oxygen saturation would indicate the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

47. The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority? a) Ineffective breathing pattern b) Excess fluid volume c) Fatigue d) Imbalanced nutrition: less than body requirements

c) Spironolactone Pg. 1395 Gynecomastia is a common side effect caused by spironolactone. Vasopressin is used for bleeding esophageal varices and is not a diuretic. Nitroglycerin (IV) may be used with vasopressin to counteract the effects of vasoconstriction from the vasopressin.

48. Gynecomastia is a common side effect of which of the following diuretics? a) Nitroglycerin (IV) b) Vasopressin c) Spironolactone d) Furosemide

d) Watery diarrhea Pg. 1382 The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.

49. The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? a) Ringing in the ears b) Asterixis c) Vomiting d) Watery diarrhea

d) Document the presence of normal bile output Pg. 1406 Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

50. A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? a) Promptly report this assessment finding to the primary provider b) Irrigate the drainage system with normal saline as prescribed c) Aspirate a sample of the drainage for culture d) Document the presence of normal bile output

b) Liver biopsy Pg. 1395 A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.

57. A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? a) Coagulation studies b) Liver biopsy c) Radioisotope liver scan d) Magnetic resonance imaging

b) Vitamin K deficiency Pg. 1384 Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency leads to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Pyridoxine deficiency results in skin and mucous membrane lesions and neurologic changes. Vitamin C deficiency results in the hemorrhagic lesions of scurvy. Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses. Folic acid deficiency results in macrocytic anemia.

6. A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? a) Riboflavin deficiency b) Vitamin K deficiency c) Folic acid deficiency d) Vitamin A deficiency

b) Endoscopic retrograde cholangiopancreatography (ERCP) Pg. 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.

60. The nurse is caring for a client suspected of having stones that have collected in the common bile duct. What test should the nurse prepare the client for that will locate these stones? a) Cholecystectomy b) Endoscopic retrograde cholangiopancreatography (ERCP) c) Colonoscopy d) Abdominal x-ray

d) Alcoholic cirrhosis Pg. 1393 This type of cirrhosis is due to 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.

61. Which term is used to describe a chronic liver disease in which scar tissue surrounds the portal areas? a) Compensated cirrhosis b) Postnecrotic cirrhosis c) Biliary cirrhosis d) Alcoholic cirrhosis

b) Measure abdominal girth daily c) Measure urine output every 8 hours d) Perform daily weights Pg. 1404 Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. 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. Monitoring the number of bowel movements is not required, though the volume would be recorded as part of output.

62. The nurse is caring for a client who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? Select all that apply. a) Assess and document vital signs every 4 hours b) Measure abdominal girth daily c) Measure urine output every 8 hours d) Perform daily weights e) Monitor number of bowel movements per day

a) The physician will use an ultrasound guided paracentesis Pg. 1374 Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions (Gordon, 2012). Ultrasound guidance may be indicated in some patients who are at high risk for bleeding because of an abnormal coagulation profile and in those who have had previous abdominal surgery and may have adhesions.

64. A patient is scheduled for a diagnostic paracentesis, but when coagulation studies were reviewed, the nurse observed they were abnormal. How does the nurse anticipate the physician will proceed with the paracentesis? a) The physician will use an ultrasound guided paracentesis b) The physician will have the nurse administer packed RBCs prior to the paracentesis. c) The physician will proceed with the paracentesis at the bedside d) The physician will not perform the procedure

d) Change in the client's handwriting and/or cognitive performance Pg. 1381 The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

66. When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? a) Constipation for more than 2 days b) Weight loss of 2 pounds in 3 days c) Anorexia for more than 3 days d) Change in the client's handwriting and/or cognitive performance

c) Asterixis Pg. 1368 Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances.

68. Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction? a) Dialysis b) Ascites c) Asterixis d) Paracentesis

b) Vasopressin Pg. 1377 Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

3. Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? a) Spironolactone b) Vasopressin c) Nitroglycerin d) Cimetidine

d) Decreased blood flow Pg. 1367 Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

13. Which is an age-related change of the hepatobiliary system? a) Enlarged liver b) Increased drug clearance capability c) Decreased prevalence of gallstones d) Decreased blood flow

a) Hemolytic Pg. 1371 Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive and hepatocellular jaundice are results of liver disease. Nonobstructive jaundice occurs with hepatitis.

16. Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a) Hemolytic b) Hepatocellular c) Obstructive d) Nonobstructive

a) A liver biopsy Pg. 1395 A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

9. A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a) A liver biopsy b) Platelet count c) A prothrombin time d) A CT scan

c) Folic acid Pg. 1384 Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.

28. Which type of deficiency results in macrocytic anemia? a) Vitamin C b) Vitamin K c) Folic acid d) Vitamin A

c) Right upper quadrant Pg. 1365 The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth surface.

59. In what location would the nurse palpate for the liver? a) Left upper quadrant b) Left lower quadrant c) Right upper quadrant d) Right lower quadrant

b) Ecchymoses d) Petechiae e) Jaundice Pg. 1368 The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

67. While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the likelihood of liver problems? Select all that apply. a) Aphthous stomatitis b) Ecchymoses c) Cyanosis of the lips d) Petechiae e) Jaundice

b) Venous pressure d) Fluid accumulation Pg. 1372-1373 Methods of treating portal hypertension aim to reduce venous pressure and fluid accumulation.

8. A client has received a diagnosis of portal hypertension. What does portal hypertension treatment aim to reduce? Select all that apply. a) Blood coagulation b) Venous pressure c) Fluid output d) Fluid accumulation

c) Excrete bile Pg. 1365 The liver forms and excretes bile, synthesizes amino acids from the breakdown of proteins, converts ammonia into urea, and synthesizes the factors needed for blood coagulation.

51. A group of students is reviewing information about the liver and associated disorders. The group demonstrates understanding of the information when they identify which of the following as a primary function of the liver? a) Breakdown amino acids b) Convert urea into ammonia c) Excrete bile d) Break down coagulation factors

a) Anorexia, nausea, and vomiting Pg. 1386 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.

11. A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a) Anorexia, nausea, and vomiting b) Severe abdominal pain radiating to the shoulder c) Eructation and constipation d) Abdominal ascites

c) Asterixis Pg. 1368 Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13).

53. 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? a) Ataxia b) Constructional apraxia c) Asterixis d) Fetor hepaticus

a) Normal activities may be resumed in 1 week Pg. A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.

65. A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when the client will be able to resume normal activities. What information should the nurse provide? a) Normal activities may be resumed in 1 week b) Normal activities may be resumed in 1 month c) Normal activities may be resumed the day after surgery d) Normal activities may be resumed in 2 weeks

c) Alpha-interferon Pg. 1389 Alpha-interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.

37. The single modality of pharmacologic therapy for chronic type B viral hepatitis is: a) Hepsera b) Baraclude c) Alpha-interferon d) Epivir

c) Vaccine Pg. 1388-1389 The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

25. Which of the following is the most effective strategy to prevent hepatitis B infection? a) Covering open sores b) Barrier protection during intercourse c) Vaccine d) Avoid sharing toothbrushes

d) "You must have the second one in 1 month and the third in 6 months" Pg. 1389-1390 Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

1. A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? a) "You must have the second one in 1 year and the third the following year" b) "You must have the second one in 2 weeks and the third in 1 month" c) "You must have the second one in 6 months and the third in 1 year" d) "You must have the second one in 1 month and the third in 6 months"

c) Vitamin K Pg. 1384 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.

24. 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? a) Potassium b) Vitamin B c) Vitamin K d) Oral bile acids

d) Level of consciousness (LOC) Pg. 1382 In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

69. A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: a) Urine output b) Stool frequency c) Abdominal girth d) Level of consciousness (LOC)