exam 1 med surg part 2
Which health promotion activity should the nurse to suggest that the client with cirrhosis add to the daily routine at home?
Abstain from drinking alcohol. Explanation: General health promotion measures include maintaining good nutrition, avoiding infection, and abstaining from alcohol. Rest and sleep are essential, but an impaired liver may not be able to detoxify sedatives and barbiturates. Such drugs must be used cautiously, if at all, by clients with cirrhosis. The client does not need to limit contact with others but should exercise caution to stay away from ill people.
The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client?
Ask family members to wash their hands frequently. Explanation: The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action. Insects do not transmit hepatitis A. Family members do not need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.
A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?
Bluish discoloration in periumbilical area Explanation: All symptoms are expected in a client with pancreatitis. However, bluish discoloration in the periumbilical area (Cullen's sign) may indicate seepage of blood stained exudate from the pancreas that may lead to hemorrhage or shock.
A 72-year-old man with cirrhosis is admitted to the hospital in a hepatic coma. What is the nurse's most important intervention?
Check airway, breathing, and circulation Explanation: Priorities include airway, breathing, and circulation. Once these are ensured, a neurological check is needed to determine status. General orientation and completing the admission may require the help and affirmation of family members. Depending on the client's alertness, orientation to the environment may need to be kept simple.
The nurse is completing a health history and physical assessment on a client admitted with esophageal varices and cirrhosis. What signs and symptoms alert the nurse to a potential internal hemorrhage?
Pulse 108 bpm, temperature 97.7°F (36.5°C), distended abdomen, and nausea Explanation: Increased pulse rate, a distended abdomen, and nausea signify the possibility of hemorrhage. The other choices are incorrect.
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 Explanation: 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's stools are light gray in color. For what finding should the nurse assess the client? Select all that apply.
intolerance to fatty foods fever jaundice Explanation: Bile is created in the liver, stored in the gallbladder, and released into the duodenum, giving stool its brown color. A bile duct obstruction can cause pale-colored stools. Other symptoms associated with cholelithiasis are right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis.
The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?
Reduced serum ammonia levels. Explanation: Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.
A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?
hyperkalemia Explanation: Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.
A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis?
Recent weight loss and temperature elevation Explanation: Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.
A client is admitted with advanced hepatic failure, including symptoms of fatigue and confusion. These symptoms are likely due to which of the following?
The liver is not breaking down the ammonia, and it acts as a neurotoxin on the brain. Explanation: The increase in toxins because the liver has lost its capacity to detoxify will result in increased blood levels. The liver is responsible for breaking down ammonia and converting it to urea, so it can be excreted by the kidneys. High ammonia levels affect all the cells of the body, but are particularly toxic to the brain. Hepatorenal syndrome will result in metabolic acidosis--both the liver and kidneys are malfunctioning. Portal hypertension causes increased back-up pressure in the digestive organs, rather than in the brain. Medications are judiciously given in hepatic failure because the liver cannot detoxify the medications.
The health care provider (HCP) instructs a client with alcohol-induced cirrhosis to stop drinking alcohol. The expected outcome of this intervention is:
improved liver function. Explanation: The goal of abstinence from alcohol in clients with alcohol-induced cirrhosis is to improve the liver function; most clients have improved liver function when they abstain from alcohol. Clients with cirrhosis do not necessarily have delirium tremens. Abstaining from alcohol may allow the client to improve nutritional status, but additional dietary counseling may be needed to achieve that goal. Clients with cirrhosis may have weight gain from ascites, but this is managed with diuretics.
A nurse is caring for a client with esophageal varices. A Sengstaken-Blakemore tube is successfully inserted to control bleeding. The nurse should:
provide the client with an emesis basin to expectorate secretions. Explanation: The Sengstaken-Blakemore tube has a gastric and an esophageal balloon that are inflated to compress bleeding esophageal varices. An inflated esophageal balloon prevents swallowing. Therefore, the nurse should provide the client with tissues and encourage him to spit into the tissues or an emesis basin. If the client cannot manage his secretions, gentle oral suctioning is needed. Oral and nasal care is provided every 1 to 2 hours. Lozenges will increase saliva production, increasing the client's risk of aspiration. A water-soluble lubricant rather than a petroleum-based lubricant is applied to the external nares. The client with a Sengstaken-Blakemore tube cannot swallow.
Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?
with each meal and snack Explanation: In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.
A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?
A low-fat, bland diet distributed over five to six small meals daily Explanation: A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition. Dietary protein and fiber are not directly related to pancreatitis. Although calcium is important, the low-fat content is more significant. The hyperglycemia of acute pancreatitis is usually transient and does not require long-term dietary modification.
A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes?
Acetaminophen. Explanation: The client with cirrhosis should be cautioned against taking any over-the-counter medications that may be hepatotoxic, because the liver will not be able to metabolize these drugs. Acetaminophen is an example of such a drug. Cimetidine, neomycin, and spironolactone are not hepatoxic, and the client can use these drugs.
A nurse is caring for a client with advanced cirrhosis. Upon assessment, the nurse notes pallor with a distended and firm abdomen. What is the most likely cause?
Ascites increasing significantly due to hypoalbuminemia Explanation: Cirrhosis often causes third-spacing that results in ascites and consequent abdominal distention. Paralytic ileus is not commonly associated with cirrhosis of the liver. Portal hypertension does not cause ascites. Bleeding esophageal varices are a significant risk, but this complication does not cause abdominal distention.
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation?
The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings are not indicative of reduced renal filtration.
A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions to manage:
severe pain. Explanation: Acute pancreatitis is very painful; management involves interventions for pain. Although alcohol abuse is often implicated in pancreatitis, drug and alcohol counseling will be an individual consideration. Risk for injury and ineffective airway clearance are not typically associated with acute pancreatitis.
The nurse teaches the client with cirrhosis that the expected outcome of taking lactulose is:
two to three soft stools per day. Explanation: The expected effect of lactulose is for the client to have two to three soft stools a day to help reduce the pH and serum ammonia levels, which will prevent hepatic encephalopathy.
A physician orders spironolactone, 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 Explanation: 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 cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan?
Discussing collaborative goals and involving the client in identifying and prioritizing important interventions Explanation: Involvement of the client in determining the goals and interventions is very important to enhance the client's compliance with the care measures. The other choices do not directly address the goals and a plan of care.
The nurse should institute which measure to prevent transmission of the hepatitis C virus to health care personnel?
decreasing contact with blood and blood-contaminated fluids Explanation: Hepatitis C is usually transmitted through blood exposure or needlesticks. A hepatitis C vaccine is currently under development, but it is not available for use. The first line of defense against hepatitis B is the hepatitis B vaccine. Hepatitis C is not transmitted through feces or urine. Wearing a gown and mask will not prevent transmission of the hepatitis C virus if the caregiver comes in contact with infected blood or needles.
The nurse should teach the client with hepatitis A to:
increase carbohydrates and protein in the diet. Explanation: Low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest obtained to promote recovery. Social isolation should be avoided, and education on preventing transmission should be provided; the client does not need to sleep in a separate room.
A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:
phytonadione. Explanation: Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client's PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer phytonadione (vitamin K1) to promote prothrombin synthesis. Spironolactone and furosemide are diuretics and have no effect on bleeding or clotting time. Warfarin is an anticoagulant that prolongs PT.
Which goal would be appropriate for a client with viral hepatitis? The client will:
verbalize the importance of reporting bleeding gums or bloody stools. Explanation: The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical manifestation of hepatitis; it is associated with cirrhosis. Alcohol use should be eliminated for at least 1 year after the diagnosis of hepatitis to allow the liver time to fully recover. There is no need for a client to be restricted to the home because hepatitis is not spread through casual contact between individuals.
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
"Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels." Explanation: Portal hypertension and hypoalbuminemia as a result of cirrhosis cause a fluid shift into the peritoneal space causing ascites. In a cardiac or kidney problem, not cirrhosis, sodium can promote edema formation and subsequent decreased urine output. Edema does not migrate upward toward the heart to enhance its circulation. Although diuretics promote the excretion of excess fluid, occasionally forgetting or omitting a dose will not yield the ascites found in cirrhosis of the liver.
The nurse is assessing a client with hepatitis A and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which statement by the client indicates the need for further instruction by the nurse?
"I take acetaminophen for arthritis pain." Explanation: Acetaminophen is toxic to the liver and should be avoided in a client with liver dysfunction. Increased periods of rest allow for liver regeneration. A low-fat, high-carbohydrate diet and dry toast to relieve nausea are appropriate.
A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response to the question?
"That's a difficult question to answer, and this must be very frightening for you." Explanation: This answer is an honest response that acknowledges the client's fears and concerns, yet does not give false reassurance.
When planning the care for a client diagnosed with hepatitis A, the nurse should include which interventions? Select all that apply.
: Provide relief from nausea and vomiting. Encourage multiple small meals daily. Plan frequent rest periods. Explanation: Clients with hepatitis A commonly experience fatigue and altered nutrition due to anorexia and nausea. Because of the severe fatigue associated with hepatitis, clients are encouraged to rest and restrict activity during the active phase of the disease. It is important that frequent rest periods be planned throughout the day. Clients may experience nausea and vomiting; thus, providing relief is important. Small, frequent meals help clients manage the anorexia associated with hepatitis. An exercise program is not appropriate due to the need for rest. Clients with hepatitis do not experience pain. All medications administered to clients with hepatitis need to be evaluated for their potential for hepatotoxicity.
A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which of the following problems is associated with cirrhosis of the liver?
Ascites related to portal hypertension Explanation: The jaundice is a result of inability of the liver to break down the end products from red blood cells, resulting in elevated bilirubin levels. Small bowel ulcerations do not occur as a result of elevated bilirubin levels and are not problems commonly associated with cirrhosis. The remaining choices are all associated with advanced cirrhosis. Ascites presents because of portal hypertension; clear dilute urine is incorrect as it would be dark due to the inability to eliminate some of the bile byproducts. Confusion and disorientation would occur when the brain is inundated by high levels of circulating toxins because of a failing liver not mental alertness and increased perception.
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?
Discuss meals that include low-fat high-carbohydrate content. Explanation: In cirrhosis, the liver's metabolic function is compromised, increasing the client's need for carbohydrates and other energy sources for cellular metabolism. The nurse should limit the client's fat intake to prevent satiation and should restrict protein intake because a cirrhotic liver can't metabolize protein effectively. A client with cirrhosis may have increased edema as a result of reduced plasma albumin, so he should restrict fluid intake rather than drink 64 oz of water daily. Increasing fiber intake isn't a priority intervention for a client with cirrhosis. A client with cirrhosis doesn't need to eliminate caffeine from his diet.
The nurse is preparing a client for paracentesis. What should the nurse do?
Have the client void before the procedure. Explanation: Before paracentesis, the client is asked to void. This is done to collapse the bladder and decrease the risk of accidental bladder perforation. The abdomen is not prepared with an antiseptic cleansing solution. The client is placed in a Fowler's position. The client does not need to be put on NPO status before the procedure.
a client with a diagnosis of cirrhosis and hepatic encephalopathy is receiving lactulose. Which assessment finding indicates a therapeutic effect of lactulose?
Improved cognition Explanation: Although lactulose is given to remove ammonia in the stool, as a laxative that will increase stool, the expected outcome is to improve client cognition. Liver enzymes do not improve when a client has cirrhosis, an irreversible form of liver dysfunction.
A client has been diagnosed with hepatitis A. Which goal is most appropriate for the client?
Increase activity levels gradually. Explanation: Viral hepatitis causes fatigue. It is important for the client to rest to allow the liver to recover. Activity levels are resumed gradually as the client begins to recover. Abdominal pain is not a common manifestation of hepatitis. The client typically does not have difficulty breathing or experience edema.
After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?
a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular Explanation: A change in a client's baseline vital signs should be brought to the HCP's attention immediately. In this case, the client's heart rate has increased, and the rhythm appears to have changed; the HCP may prescribe an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the HCP information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the HCP attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the HCP but only after all of the immediate physical and psychological needs of all clients have been met.
A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. The nurse should:
assess for gastrointestinal (GI) bleeding. Explanation: Clients with cirrhosis can develop hepatic encephalopathy caused by increased ammonia levels. Asterixis, a flapping tremor, is a characteristic symptom of increased ammonia levels. Bacterial action on increased protein in the bowel will increase ammonia levels and cause the encephalopathy to worsen. GI bleeding and protein consumed in the diet increase protein in the intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the intestine and should not be held since neurological symptoms are worsening. Bilirubin is associated with jaundice.
A client with hepatitis C develops complications of liver failure including a prolonged prothrombin time (PT) and partial-prothrombin time (PTT). The client is told to anticipate blood products to be administered today and asks the nurse what the blood products will be. What should the nurse tell the client?
cryoprecipitate and fresh frozen plasma Explanation: The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These products include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, these products aren't specifically used to treat hemostasis. Although platelets may be helpful, the best answer is cryoprecipitate and fresh frozen plasma.
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing?
decreased mental status Explanation: The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.
excessive alcohol use gallstones abdominal trauma hyperlipidemia with excessive triglycerides Explanation: Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.
The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by:
observing stools for steatorrhea. Explanation: If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the health care provider (HCP) of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy?
potassium Explanation: Hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy; an increase in creatinine would indicate renal insufficiency. With liver dysfunction, increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema.
The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client comes upset when the health care provider (HCP) persists in asking about alcohol intake. The nurse should explain that the reason for these questions is that:
there is a strong link between alcohol use and acute pancreatitis. Explanation: Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.
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. Explanation: To maintain enteric precautions, the nurse must wash her hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.
A client with cirrhosis should be encouraged to follow which diet?
well-balanced normal nutrients, low-sodium diet Explanation: Cirrhosis is a slowly progressive disease. Inadequate nutrition is the primary ongoing problem. Clients are encouraged to eat normal, well-balanced diets and to restrict sodium to prevent fluid retention. There is no need to increase calories or potassium or to adopt a bland diet. Protein is not restricted until the liver actually fails, which is usually late in the disease.
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
Increased drowsiness Explanation: Although all the options are associated with hepatitis B, the onset of drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions. Yellow sclera, pruritus, and fatigue are expected with hepatitis B infection and do not indicate worsening of liver function.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
obtain adequate bed rest. Explanation: Treatment of hepatitis consists primarily of bed rest with bathroom privileges. Bed rest is maintained during the acute phase to reduce metabolic demands on the liver, thus increasing its blood supply and promoting liver cell regeneration. When activity is gradually resumed, the client should be taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not necessary to force fluids to treat hepatitis. Antibiotics are not used to treat hepatitis. Electrolyte imbalances are not typical of hepatitis.
The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply.
Prothrombin time 22 seconds Ammonia 96 mg/dL (68.54 mmol/L) Platelets 75,000 cells/mm3 (75 x 109/L) Explanation: The client with cirrhosis has liver dysfunction and impaired coagulation and rising ammonia levels. The prothrombin time is prolonged (normal is 10 to 13.0 seconds), and the platelet count is low (normal is 150,000 to 350,000 cells/mm3). A normal ammonia level is 15 to 45 mg/dl (10.71 mmol/L- 32.13 mmol/L), and this client's level is elevated, placing the client at risk for hepatic encephalopathy. A client with cirrhosis typically has hypokalemia because of the diuretic therapy used to treat the fluid retention associated with the disease. Here, the potassium level is within normal limits (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). In cirrhosis, the albumin level is also typically low (normal is 3.5 to 5.0 g/dl or 35-50 g/L) due to alterations in protein metabolism in the liver. Levels of amylase, a pancreatic enzyme, typically increase with pancreatitis, not cirrhosis (normal level is 27 to 151 units/L or 0.45 mkat/L to 2.52mkat/L).
The client with cirrhosis who has ascites receives 100 mL of 25% serum albumin I.V. Which finding would best indicate that the albumin is having its desired effect?
reduced ascites Explanation: Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites formation, results in decreased colloid osmotic pressure. Administering serum albumin increases the plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma. Increased urine output is the best indication that the albumin is having the desired effect. An increased serum albumin level and increased ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites. However, it is not as direct an indicator as increased urine output and reduced ascites. Anorexia is not affected by the administration of albumin.
A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?
Ineffective breathing pattern Explanation: In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.
When assessing a client who has been diagnosed with hepatic cirrhosis, the nurse should obtain which information when conducting a focused assessment? Select all that apply.
current use of alcohol nutritional status. mental status Explanation: For the client with hepatic cirrhosis, it would be important to assess the client's current use of alcohol because alcohol consumption can have a significant impact on liver function and is, in fact, the major cause of cirrhosis. Continued use of alcohol further destroys liver cells and affects liver function. Assessing the client's nutritional status is also important because impaired nutrition develops in many clients due to gastrointestinal problems and the inability of the liver to metabolize nutrients. Mental status can be affected by the accumulation of ammonia in the blood, leading to hepatic coma if left untreated. The assessments of heart sounds and capillary refill time, while important components of a physical examination, are not priority assessments in the client with cirrhosis.
