Med Surg I Prep U Chapter 49: Assessment and Management of Patients With Hepatic Disorders

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

"You must have the second one in 1 month and the third in 6 months."

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?

A liver biopsy

The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed?

Abdominal paracentesis

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?

Asterixis

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?

Clay-colored or whitish

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Clay-colored stools

Which is an age-related change of the hepatobiliary system?

Decreased blood flow

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP)

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?

Ineffective breathing pattern

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

Liver biopsy

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine.

Which assessments are important in a client diagnosed with ascites?

Measurement of abdominal girth

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease?

Pad the side rails on the bed

Which is the most common cause of esophageal varices?

Portal hypertension

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?

Respiratory assessment related to increased thoracic pressure

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?

Scurvy

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia?

Spironolactone (Aldactone)

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?

The client's hepatic function is decreasing.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

The digestion of dietary and blood proteins.

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose?

Watery diarrhea

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

anorexia, nausea, and vomiting.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration.

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that most likely bring about hemostasis in the client are:

cryoprecipitate and fresh frozen plasma.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response?

decompression

Which symptoms will a nurse observe most commonly in clients with pancreatitis?

severe, radiating abdominal pain

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

Which of the following the are early manifestations of liver cancer? Select all that apply.

• Pain • Continuous aching in the back

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance

When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following?

Caput medusae

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

Hepatitis C increases a person's risk for liver cancer.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

Hypotension

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

Lactulose

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure.

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?

Vitamin A

A physician orders spironolactone (Aldactone), 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

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

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K

A client has received a diagnosis of portal hypertension. What does portal hypertension treatment aim to reduce? Select all that apply.

• fluid accumulation • venous pressure