med-surg chp 49

Decompensated cirrhosis s/s

-ascites -jaundice -weakness -muscle wasting -weight loss -continuous mild fever -clubbing of the fingers -purpura (due to decreased platelet count) -spontaneous bruising -epitaxis -hypotension -sparse body hair -white nails -gonadal atrophy

Compensated cirrhosis s/s

-intermittent mild fever -vascular spiders -palmar and erythema (reddened palms) -unexpected epitaxis -ankle edema -vague morning indigestion -flatulent dyspepsia -abd pain -firm, enlarged liver -splenomegaly

Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. A nurse is reviewing laboratory test results from a client. The report indicates that the client has jaundice. What serum bilirubin level must the client's finding exceed? Enter the correct number only

2.5 Correct Explanation: Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.5 mg/dL (43 fmol/L).

A nurse is teaching a patient about the types of chronic liver disease. The patient's teaching is determined to be effective based on the correct identification of which of the following types of cirrhosis caused by scar tissue surrounding the portal areas? a) Postnecrotic cirrhosis b) Biliary cirrhosis c) Compensated cirrhosis d) Alcoholic cirrhosi

Alcoholic cirrhosis Explanation: Alcoholic cirrhosis, in which the scar tissue characteristically surrounds the portal areas, is most frequently caused by chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

When caring for a patient with advanced cirrhosis and hepatic encephalopathy, which of the following assessment findings should the nurse report immediately? a) Weight loss of 2 pounds in 3 days b) Change in the patient's handwriting and or cognitive performance c) Anorexia for more than 3 days d) Constipation for more than 2 days

Change in the patient's handwriting and or cognitive performance Correct Explanation: The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The patient appears confused and unkempt and has alterations in mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the patient's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Cholecystectomy b) Endoscopic retrograde cholangiopancreatography (ERCP) c) Abdominal x-ray d) Colonoscopy

Correct response: Endoscopic retrograde cholangiopancreatography (ERCP) Explanation: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder. (less)

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 and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client is avoiding the nurse. b) The client's hepatic function is decreasing. c) The client is relaxed and not in pain. d) The client didn't take his morning dose of lactulose (Cephulac).

Correct response: 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 don't indicate that the client is relaxed or avoiding the nurse.

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Maintaining fluid volume b) Relieving the patient's anxiety c) Maintaining the airway d) Controlling bleeding

Maintaining the airway Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation. (less)

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? a) Urinary output related to increased sodium retention b) Skin assessment related to increase in bile salts c) Peripheral vascular assessment related to immobility d) Respiratory assessment related to increased thoracic pressure

Respiratory assessment related to increased thoracic pressure Correct Explanation: If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy. (less)

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Vaccine b) Avoid sharing toothbrushes c) Barrier protection during intercourse d) Covering open sores

Vaccine Correct Explanation: The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? a) Riboflavin b) Thiamine c) Vitamin K d) Vitamin A

Vitamin A Correct Explanation: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: a) stool frequency. b) abdominal girth. c) urine output. d) level of consciousness (LOC).

level of consciousness (LOC). Explanation: In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose. (less)