Chapter 53
A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for patients on airborne precautions
A. Disposing of sharps appropriately and not recapping needles
A nurse educate is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunizations B. Use of standard precautions C. Consumption of vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B12 injections
A. Immunizations B. Use of standard precautions
A patient with a history of injection drug use has been diagnosed with Hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D. Administration of fresh-frozen plasma (FFP)
B. A regimen of antiviral medications
A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptoms resolution. B. Adhere to dosing recommendations of OTC analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.
B. Adhere to dosing recommendations of OTC analgesics.
A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient stated that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the patient's commode and supply a bedpan B. Complete an incident report and submit it to the unit supervisor C. Have the patient assessed by the physician due to the risk of internal bleeding D. Perform a focused abdominal assessment in order to rule out injury.
C. Have the patient assessed by the physician due to the risk of internal bleeding
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection
D. An immune globulin injection
The nurse is caring for a client who has a risk gene for developing cirrhosis. Whichracial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French
c. Latinos
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the patient's sodium intake does not exceed recommended levels B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy C. Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.
B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy
A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool.
b. The patient uses witch hazel compresses to soothe irritation.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."
c. "I need to avoid protein in my diet."
The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."
d. "Report any changes in urinary elimination while on this drug."
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.
d. Assess the client for airway patency.
The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C
d. Hepatitis C
What should the nurse plan to teach about to a patient with Crohn's disease who has megaloblastic anemia? a. Iron dextran infusions b. Oral ferrous sulfate tablets c. Routine blood transfusions d. Cobalamin (B12) supplements
d. Cobalamin (B12) supplements
The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy f. Respiratory therapy
c. Feet elevated on pillows d. Daily weights f. Respiratory therapy
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the client." c. "For the client's oral care, use a soft toothbrush." d. "Provide clippers so the client can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."
a. "Apply lotion to the client's dry skin areas." c. "For the client's oral care, use a soft toothbrush." d. "Provide clippers so the client can trim the fingernails."
The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
a. "Hepatitis C is not spread through casual contact."
The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"
a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"
Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "I should apply sunscreen before going outdoors." b. "The medication will be tapered if I need surgery." c. "I will need to avoid contact with people who are sick." d. "The medication prevents the infections that cause diarrhea."
a. "I should apply sunscreen before going outdoors."
A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
b. "Viral hepatitis is not spread through casual contact."
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."
c. "I will help you identify a support system."
The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."
c. "I will help you identify a support system."
A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Skin is dry with tenting and poor turgor. b. Patient has not voided for the last 2 hours. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.
c. Crackles are heard halfway up the posterior chest.
A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.
b. Assist the client to void before the procedure
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. What should the nurse include in the plan of care? a. Administer IV metoclopramide (Reglan). b. Discontinue the patient's oral food intake. c. Administer cobalamin (vitamin B12) injections. d. Teach the patient about total colectomy surgery.
b. Discontinue the patient's oral food intake.
A nose obtains a clients's health history at a community health clinic. Which statement alerts the nurse to prove health teaching to this client? a. "I drink two glasses of red wine each week." b. "I take a lot of Tylenol for my arthritis pain." c. "I have a cousin who died of liver cancer." d. "I got a hepatitis vaccine before traveling."
b. "I take a lot of Tylenol for my arthritis pain."
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to 3 soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool
A. Two to 3 soft bowel movements daily
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing
B. Assessment for variceal bleeding
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degree to right side of the abdomen and push down firmly.
C. Place hand under right lower rib cage and press down lightly with the other hand.
A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy
a. Oxygen therapy c. Feet elevated on pillows d. Daily weights
The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding
a. History of hepatitis B
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.
b. Provide a low-sodium diet.
The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine
a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine
A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A. By considering that patient's age and prognosis B. By objectively determining the patient's medical need C. By objectively assessing the patient's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options
B. By objectively determining the patient's medical need
The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."
a. "Diarrhea is expected; that's how your body gets rid of ammonia."
The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."
a. "Apply lotion to the client's dry skin areas." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails."
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."
b. "I may have been exposed when we ate shrimp last weekend."
After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What should the nurse plan to teach the patient? a. Medication use b. Fluid restriction c. Enteral nutrition d. Activity restrictions
a. Medication use
A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)
b. Elevated international normalized ratio (INR) e. Elevated serum ammonia f. Elevated prothrombin time (PT)
A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)
b. Elevated international normalized ratio (INR) e. Elevated serum ammonia f. Elevated prothrombin time (PT)
The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis
b. Polyarthritis c. Heart disease d. Myalgia
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. "I should drink bottled water during my travels." b. "I will not eat off another's plate or share utensils." c. "I should eat plenty of fresh fruits and vegetables." d. "I will wash my hands frequently and thoroughly."
c. "I should eat plenty of fresh fruits and vegetables."
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."
a. "Diarrhea is expected; that's how your body gets rid of ammonia."
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner
a. A 20-year-old college student who has had several sexual partners
Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.
a. Encourage the patient to express concerns and ask questions about IBS.
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the client gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
b. "Less protein in the diet will help prevent confusion associated with liver failure."
The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)
a. Urine output via indwelling urinary catheter is 20 mL/hr
The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
b. "Less protein in the diet will help prevent confusion associated with liver failure."
The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.
b. Provide a low-sodium diet.
A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Fistulas can form between the bowel and bladder. b. Bacteria in the perianal area can enter the urethra. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.
a. Fistulas can form between the bowel and bladder.
The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia
a. Infection b. GI bleeding d. Constipation f. Hypovolemia
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education? a. "Use a pill organizer to ensure you take this medication as prescribed." b. "Transient muscle aching is a common side effect of this medication." c. "Follow up with your provider in 1 week to test your blood for toxicity." d. "Take your radial pulse for 1 minute prior to taking this medication."
a. "Use a pill organizer to ensure you take this medication as prescribed."
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!" Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the client's diuretic.
a. Instruct the client to sit in as upright a position as possible.
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner
a. Policies related to consistent use of Standard Precautions c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the client's weight by 6 kg
a. Urine output via indwelling urinary catheter is 20 mL/hr
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."
b. "I may have been exposed when we ate shrimp last weekend."
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I cannot drink any alcohol at all anymore." b. "I need to avoid protein in my diet." c. "I should not take over-the-counter medications." d. "I should eat small, frequent, balanced meals."
b. "I need to avoid protein in my diet."
Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"
d. "How long have you had abdominal pain?"
The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.
d. Assist the client to void before the procedure.
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain
d. Mid-sternal chest pain