Ch. 49: Assessment and Management of Patients with Hepatic Disorders
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) Blood pH of 7.25 b) Serum sodium level of 135 mEq/L c) Loss of 2.2 lb (1 kg) in 24 hours d) Serum potassium level of 3.5 mEq/L
Loss of 2.2 lb (1 kg) in 24 hours 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
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) Vitamin A b) Thiamine c) Riboflavin d) Vitamin K
Vitamin A Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.
A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when he will be able to resume normal activities. What information should the nurse provide? a)Normal activities may be resumed in 1 month. b)Normal activities may be resumed in 2 weeks. c)Normal activities may be resumed in 1 week. d)Normal activities may be resumed the day after surgery.
Normal activities may be resumed in 1 week. A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.
Which of the following is the most effective strategy to prevent hepatitis B infection? a)Vaccine b)Barrier protection during intercourse c)Avoid sharing toothbrushes d)Covering open sores
Vaccine 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.
Which type of deficiency results in macrocytic anemia? a) Folic acid b) Vitamin A c) Vitamin K d) Vitamin C
Folic acid 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
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)Bumetanide (Bumex) b)Furosemide (Lasix) c)Acetazolamide (Diamox) d)Spironolactone (Aldactone)
Spironolactone (Aldactone) 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.
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 1 month and the third in 6 months." d) "You must have the second one in 6 months and the third in 1 year."
"You must have the second one in 1 month and the third in 6 months." 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.
The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? a) Hemolytic b) Nonobstructive c) Hepatocellular d) Obstructive
Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? a) Hepatic encephalopathy b) Portal hypertension c) Asterixis d) Cirrhosis
Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.
A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures? a)Abdominal ultrasound b)Paracentesis c)Liver biopsy d)Dialysis
Paracentesis 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. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.
What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Colonoscopy b) Endoscopic retrograde cholangiopancreatography (ERCP) c) Cholecystectomy d) Abdominal x-ray
Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.
The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Blood c) Fecal-oral d) Saliva
Fecal-oral 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.
Timothy is a client being treated for hepatitis in the infectious disease office where you practice nursing. He has a history of IV drug use. He presents today with jaundice and arthralgias. Timothy most likely has which type of hepatitis? a) Hepatitis A b) Hepatitis E c) Hepatitis B d) Hepatitis C
Hepatitis B Mode of transmission is from infected blood or plasma, needles, syringes, surgical or dental equipment contaminated with infected blood; also sexually transmitted through vaginal secretions and semen of carriers or those actively infected. Mode of transmission is similar to HBV, although less severe and without jaundice. The client's presentation is most similar to hepatitis B. Mode of transmission is the oral route from feces and saliva of infected persons. The client's presentation is most similar to hepatitis B. Mode of transmission is similar to HAV. The client's presentation is most similar to hepatitis B.
A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Relieving the patient's anxiety b) Maintaining fluid volume c) Maintaining the airway d) Controlling bleeding
Maintaining the airway 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 is 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.
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? a) Gynecomastia and testicular atrophy b) Dyspnea and fatigue c) Ascites and orthopnea d) Purpura and petechiae
Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
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) Vitamin K b) Oral bile acids c) Potassium d) Vitamin B
Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.
A client 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)cirrhosis. c)cholelithiasis. d)appendicitis.
Cirrhosis Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.
A 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 CT scan b) Platelet count c) A liver biopsy d) A prothrombin time
A liver biopsy 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.
A patient complaining of shortness of breath is admitted with the 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? a)Bilirubin b)Temperature c)Albumin d)Hemoglobin
Albumin With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity. The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema.
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a) Clay-colored or whitish b) Yellow-green c) Black and tarry d) Blood tinged
Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Palpation of abdomen for a fluid shift b) Measurement of abdominal girth c) Weight d) Foul-smelling breath
Foul-smelling breath Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.
Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a)Hemolytic b)Nonobstructive c)Hepatocellular d)Obstructive
Hemolytic Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.
A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a)Infection with hepatitis G is similar to hepatitis A. b)Hepatitis C increases a person's risk for liver cancer. c)Hepatitis A is frequently spread by sexual contact. d)Hepatitis B is transmitted primarily by the oral-fecal route.
Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
The most common cause of esophageal varices includes which of the following? a)Portal hypertension b)Jaundice c)Asterixis d)Ascites
Portal hypertension 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.
Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? a)Spironolactone (Aldactone) b)Nitroglycerin c)Vasopressin (Pitressin) d)Cimetidine (Tagamet)
Vasopressin (Pitressin) Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.
Which of the following indicates an overdose of lactulose? a) Watery diarrhea b) Fecal impaction c) Constipation d) Hypoactive bowel sounds
Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a) anorexia, nausea, and vomiting. b) eructation and constipation. c) abdominal ascites. d) severe abdominal pain radiating to the shoulder.
anorexia, nausea, and vomiting. 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.
A nurse in the surgical ICU just received a client from recovery following a Whipple procedure. Which of the following nursing diagnoses should the nurse consider when caring for this acutely ill client? Select all that apply. a) Alterations in respiratory function b) Acute pain and discomfort c) Potential for infection d) Fluid volume excess
• Alterations in respiratory function • Acute pain and discomfort • Potential for infection Monitor for potential for infection related to invasive procedure and poor physical condition. Monitor for pain related to extensive surgical incision. Monitor for alterations in respiratory function related to extensive surgical incisions, immobility, and prolonged anesthesia. Client is at risk for fluid volume deficit related to hemorrhage and loss of fluids.
The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? a) Peripheral vascular assessment related to immobility b) Respiratory assessment related to increased thoracic pressure c) Urinary output related to increased sodium retention d) Skin assessment related to increase in bile salts
Respiratory assessment related to increased thoracic pressure If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.
A client with 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) elevated blood urea nitrogen and creatinine levels and hyperglycemia. b) subnormal clotting factors and platelet count. c) elevated liver enzymes and low serum protein level. d) subnormal serum glucose and elevated serum ammonia levels.
subnormal serum glucose and elevated serum ammonia levels. 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.
