Ch 49

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching?

"How did this happen? I've been faithful my entire marriage."

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?

"You must have the second one in 1 month and the third in 6 months."

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor?

Albumin

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?

Ammonia

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?

Asterixis

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?

Clay-colored or whitish

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Clay-colored stools

Which is an age-related change of the hepatobiliary system?

Decreased blood flow

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP)

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

Fecal-oral

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

Hemolytic

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.

Hemorrhoids Ascites Enlarged liver size

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

Hepatitis C increases a person's risk for liver cancer.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

Hypotension

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?

Lactulose

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?

Liver biopsy

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?

Loss of 2.2 lb (1 kg) in 24 hours

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?

Obstructive jaundice

Which of the following the are early manifestations of liver cancer? Select all that apply.

Pain Continuous aching in the back

Which is the most common cause of esophageal varices?

Portal hypertension

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure.

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern?

The client's hands flap back and forth when the arms are extended.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

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

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?

Vitamin K

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?

Vitamin K deficiency

Which condition indicates an overdose of lactulose?

Watery diarrhea

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

anorexia, nausea, and vomiting.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration.

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.

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

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:

subnormal serum glucose and elevated serum ammonia levels.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

wash her hands after touching the client.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy

Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?

Asterixis

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

Octreotide

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