Chp 43 TB (Cirrhosis)
38. The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for: A. jaundice. B. bleeding. C. malnutrition. D. hypokalemia.
ANS: A Rationale: Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.0 mg/dL (34 mmol/L). Elevated bilirubin levels are not associated with hypokalemia, malnutrition or bleeding, though these complications may result from the underlying liver disorder. PTS: 1 REF: p. 1371 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
1. A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K
ANS: D Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin. PTS: 1 REF: p. 1366 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice
15. A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to three 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
ANS: A Rationale: Lactulose is given to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the client's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool. PTS: 1 REF: p. 1383 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice
6. A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? A. "How many alcoholic drinks do you typically consume in a week?" B. "To the best of your knowledge, are your immunizations up to date?" C. "Have you ever worked in an occupation where you might have been exposed to toxins?" D. "Has anyone in your family ever experienced symptoms similar to yours?"
ANS: A Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease. PTS: 1 REF: p. 1367 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
8. A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. Asterixis B. Constructional apraxia C. Fetor hepaticus D. Palmar erythema
ANS: A Rationale: The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor. PTS: 1 REF: p. 1381 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice
19. A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)
ANS: A, C, D Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel. PTS: 1 REF: p. 1369 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select
30. A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing client positioning
ANS: A, C, E Rationale: Administering diuretics, implementing fluid restrictions, and enhancing client positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem. PTS: 1 REF: p. 1399 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select
24. A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep client NPO until the results of test are known. B. Keep client NPO until the client's gag reflex returns. C. Administer analgesia until post-procedure tenderness is relieved. D. Give the client a cold beverage to promote swallowing ability.
ANS: B Rationale: After the examination, fluids are not given until the client's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the client's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns. PTS: 1 REF: p. 1376 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
22. A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client'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
ANS: B Rationale: Esophageal varices are a major cause of mortality in clients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed. PTS: 1 REF: p. 1375 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
29. A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the client's sodium intake does not exceed recommended levels. B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. C. Inform the primary provider that the client should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.
ANS: B Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the client's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the client's physiologic deterioration. PTS: 1 REF: p. 1404 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice
33. A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client reports falling when transferring to the commode. The client'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 client's commode and supply a bedpan. B. Complete an incident report and submit it to the unit supervisor. C. Have the client assessed by the primary provider due to the risk of internal bleeding. D. Perform a focused abdominal assessment in order to rule out injury.
ANS: C Rationale: A fall would necessitate thorough medical assessment due to the client's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate. PTS: 1 REF: p. 1403 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
20. A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. Increased potassium intake B. Fluid restriction to 2 L per day C. Reduction in sodium intake D. High-protein, low-fat diet
ANS: C Rationale: Clients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake. PTS: 1 REF: p. 1375 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
3. A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? A. Assessment of blood pressure and assessment for headaches and visual changes B. Assessments for signs and symptoms of venous thromboembolism C. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h
ANS: C Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE. PTS: 1 REF: p. 1373 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
37. A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk? A. Chronic jaundice B. Pigment stones in portal circulation C. Central nervous system damage D. Hepatomegaly
ANS: C Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin. PTS: 1 REF: p. 1371 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice
23. A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? A. Decisional conflict B. Deficient knowledge C. Death anxiety D. Disturbed thought processes
ANS: C Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the client's likely fear of death, which is a realistic possibility. For most clients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The client may or may not experience disturbances in thought processes. PTS: 1 REF: p. 1378 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice
2. A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client'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 degrees to right side of the abdomen and push down firmly.
ANS: C Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant. PTS: 1 REF: p. 1369 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
25. A client with esophageal varices is being cared for in the ICU. The varices have begun to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also anticipate what intervention? A. Positioning the client supine B. Administering diuretics C. Oxygen by nasal cannula D. Administering volume expanders
ANS: D Rationale: Because clients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. Supine positioning could exacerbate bleeding because of the effects of gravity. Nasal cannula are unlikely to meet the client's oxygenation needs. PTS: 1 REF: p. 1377 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice
7. A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparin B. IV administration of albumin C. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide
ANS: D Rationale: Octreotide—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not given, and heparin would exacerbate, not alleviate, bleeding. PTS: 1 REF: p. 1377 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
16. A nurse is performing an admission assessment for an 81-year-old client who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver
ANS: D Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges. PTS: 1 REF: p. 1367 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice
21. A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as prescribed C. Vitamin B12 injections as prescribed D. Administration of diuretics as prescribed
ANS: D Rationale: Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary. PTS: 1 REF: p. 1373 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice
