chapter 39 and 44 evolve
12. When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? A "I will use care when kissing my wife to prevent giving it to her." B "I will need to take adofevir (Hepsera) to prevent chronic HCV." C "Now that I have had HCV, I will have immunity and not get it again." D "I will need to be checked for chronic HCV and other liver problems."
"I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.
14. The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." "I need to take good care of my belly and ankle skin where it is swollen." "A scrotal support may be more comfortable when I have scrotal edema." "I can use pillows to support my head to help me breathe when I am in bed."
"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Correct If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.
A 25-year-old patient with a group A streptococcal pharyngitis does not want to take the antibiotics prescribed. What should the nurse tell the patient to encourage the patient to take the medications and avoid complications of the infection? A "The complications of this infection will affect the skin, hair, and balance." B "You will not feel well if you do not take the medicine and get over this infection." C "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." D "You may not want to take the antibiotics for this infection, but you will be sorry if you do not."
"Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." Rheumatic fever (RF) is not common because of effective use of antibiotics to treat streptococcal infections. Without treatment, RF can occur and lead to rheumatic heart disease, especially in young adults. The complications do not include hair or balance. Saying that the patient will not feel well or that the patient will be sorry if the antibiotics are not taken is threatening to the patient and inappropriate for the nurse to say.
18. When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.
A lower-fat diet may be better tolerated for several weeks. Correct Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.
13. The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? a There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. b Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. c Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. d Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. e Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.
A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Correct B Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Correct C Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.
5. When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A Use smallest gauge needle possible when giving injections or drawing blood. B Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D Apply gentle pressure for the shortest possible time period after performing venipuncture. E Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
A. Use smallest gauge needle possible when giving injections or drawing blood B Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Correct Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.
11. A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A Low-grade fever of 100° F and dehydration B Abscess in the right upper quadrant of the abdomen C Activated partial thromboplastin time (aPTT) of 54 seconds D Multiple obstructions in the cystic and common bile duct
Activated partial thromboplastin time (aPTT) of 54 seconds An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.
1.A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? A Malnutrition B Osteomyelitis C Alcohol abuse D Diabetes mellitus
Alcohol abuse The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.
3.The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? A "The hepatitis vaccine will provide immunity from this exposure and future exposures." B "I am afraid there is nothing you can do since the patient was infectious before admission." C "You will need to be tested first to make sure you don't have the virus before we can treat you." D "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."
An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure. Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.
The patient had a history of rheumatic fever and has been diagnosed with mitral valve stenosis. The patient is planning to have a biologic valve replacement. What protective mechanisms should the nurse teach the patient about using after the valve replacement? A Long-term anticoagulation therapy B Antibiotic prophylaxis for dental care C Exercise plan to increase cardiac tolerance D Take β-adrenergic blockers to control palpitations.
Antibiotic prophylaxis for dental care The patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis. Long-term anticoagulation therapy is not used with biologic valve replacement unless the patient has atrial fibrillation. An exercise plan to increase cardiac tolerance is needed for a patient with heart failure. Taking β-adrenergic blockers to control palpitations is prescribed for mitral valve prolapse, not valve replacement.
17. The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? a Spiral CT scan b A PET/CT scan c Abdominal ultrasound d Cancer-associated antigen 19-9
Cancer-associated antigen 19-9 Correct The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.
10.The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? A Prevent all oral intake. B Control abdominal pain. C Provide enteral feedings. D Avoid dietary cholesterol.
Control abdominal pain. Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.
The patient had myocarditis and is now experiencing fatigue, weakness, palpitations, and dyspnea at rest. The nurse assesses pulmonary crackles, edema, and weak peripheral pulses. Sinoatrial tachycardia is evident on the cardiac monitor. The Doppler echocardiography shows dilated cardiomyopathy. What collaborative and nursing care of this patient should be done to improve cardiac output and the quality of life? (Select all that apply.) A Decrease preload and afterload. B Relieve left ventricular outflow obstruction. C Control heart failure by enhancing myocardial contractility. D Improve diastolic filling and the underlying disease process. E Improve ventricular filling by reducing ventricular contractility.
Decrease preload and afterload. Control heart failure by enhancing myocardial contractility. The patient is experiencing dilated cardiomyopathy. To improve cardiac output and quality of life, drug, nutrition, and cardiac rehabilitation will be focused on controlling heart failure by decreasing preload and afterload and improving cardiac output, which will improve the quality of life. Relief of left ventricular outflow obstruction and improving ventricular filling by reducing ventricular contractility is done for hypertrophic cardiomyopathy. There are no specific treatments for restrictive cardiomyopathy, but interventions are aimed at improving diastolic filling and the underlying disease process.
2.The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A Relief of constipation B Relief of abdominal pain C Decreased liver enzymes D Decreased ammonia levels
Decreased ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.
1. While doing an admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which disease process? A Endocarditis B Acute kidney injury C Myocardial infarction D Chronic thrombophlebitis
Endocarditis Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and/or prolonged oxygen deficiency. Clinical manifestations of acute kidney injury, myocardial infarction, and chronic thrombophlebitis will not include clubbing of the fingers.
9.The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A Serum α-fetoprotein level B Ventilation/perfusion scan C Hepatic structure ultrasound D Abdominal girth measurement
Hepatic structure ultrasounD Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.
8.A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? A Tramadol (Ultram) B Hydromorphone (Dilaudid) C Oxycodone with aspirin (Percodan) D Hydrocodone with acetaminophen (Vicodin)
Hydrocodone with acetaminophen (Vicodin) The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.
4.When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A Impaired skin integrity related to edema, ascites, and pruritus B Imbalanced nutrition: less than body requirements related to anorexia C Excess fluid volume related to portal hypertension and hyperaldosteronism D Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.
16. The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? a Immediately start enteral feeding to prevent malnutrition. b. Insert an NG and maintain NPO status to allow pancreas to rest. c. Initiate early prophylactic antibiotic therapy to prevent infection. d. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
Insert an NG and maintain NPO status to allow pancreas to rest. Correct Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
6.A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? A Milk thistle may affect liver enzymes and thus alter drug metabolism. B Milk thistle is generally safe in recommended doses for up to 10 years. C There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.
Milk thistle may affect liver enzymes and thus alter drug metabolism. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
The patient with pericarditis is complaining of chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? A Corticosteroids B Morphine sulfate C Proton pump inhibitor D Nonsteroidal antiinflammatory drugs
Nonsteroidal antiinflammatory drugs Nonsteroidal antiinflammatory drugs (NSAIDs) will control pain and inflammation. Corticosteroids are reserved for patients already taking corticosteroids for autoimmune conditions or those who do not respond to NSAIDs. Morphine is not necessary. Proton pump inhibitors are used to decrease stomach acid to avoid the risk of GI bleeding from the NSAIDs.
4. When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations (select all that apply)? A Osler's nodes B Janeway's lesions C Splinter hemorrhages D Subcutaneous nodules E Erythema marginatum lesions
Osler's nodes Janeway's lesions Splinter hemorrhages Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever.
An 80-year-old patient with uncontrolled type 1 diabetes mellitus is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? A Aortic valve replacement B Take nitroglycerin for chest pain. C Open commissurotomy (valvulotomy) procedure D Percutaneous transluminal balloon valvuloplasty (PTBV) procedure
Percutaneous transluminal balloon valvuloplasty (PTBV) procedure The percutaneous transluminal balloon valvuloplasty (PTBV) procedure is best for this older adult patient who is a poor surgery candidate related to the uncontrolled type 1 diabetes mellitus. Aortic valve replacement would probably not be tolerated well by this patient, although it may be done if the PTBV fails and the diabetes is controlled in the future. Nitroglycerin is used cautiously for chest pain because it can reduce BP and worsen chest pain in patients with aortic stenosis. Open commissurotomy procedure is used for mitral stenosis.
2. While admitting a patient with pericarditis, the nurse will assess for what manifestations of this disorder? A Pulsus paradoxus B Prolonged PR intervals C Widened pulse pressure D Clubbing of the fingers
Pulsus paradoxus Correct Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus greater than 10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis. Prolonged PR intervals occur with first-degree AV block. Widened pulse pressure occurs with valvular heart disease. Clubbing of fingers may occur in subacute forms of infective endocarditis and valvular heart disease.
3. The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? A Respiratory rate of 18 and heart rate of 90 B Regurgitant murmur at the mitral valve area C Heart rate of 94 and capillary refill time of 2 seconds D Point of maximal impulse palpable in fourth intercostal space
Regurgitant murmur at the mitral valve area A regurgitant murmur of the aortic or mitral valves would indicate valvular disease, which is a complication of endocarditis. All the other findings are within normal limits.
5. What nursing action should the nurse prioritize during the care of a patient who has recently recovered from rheumatic fever? A Teach the patient how to manage his or her physical activity. B Teach the patient about the need for ongoing anticoagulation. C Teach the patient about the need for continuous antibiotic prophylaxis. D Teach the patient about the need to maintain standard infection control procedures.
Teach the patient about the need for continuous antibiotic prophylaxis. Correct Patients with a history of rheumatic fever frequently require ongoing antibiotic prophylaxis, an intervention that necessitates education. This consideration is more important than activity management in preventing recurrence. Anticoagulation is not indicated in this patient population. Standard precautions are indicated for all patients.
15. The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? a Has completed a college education b Has been able to stop smoking cigarettes c Has well-controlled type 1 diabetes mellitus d The chest x-ray showed another lung cancer lesion.
The chest x-ray showed another lung cancer lesion. Correct Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.
7.When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? A Vitamin A B Vitamin D C Vitamin E D. Vitamin K E. Vitamin B
Vitamin A Vitamin D Vitamin E Vitamin K Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.