Medical Surgical Chapter 30

bleeding

A client is scheduled for a liver biopsy. The nurse realizes that the most important sign to assess for is:

Preicteric

A client who usually smokes a pack of cigarettes a day tells the nurse that he cannot stand the smell of smoke. The nurse realizes that this client is in which phase of hepatitis?

Females often do not experience the effects of the disease until menopause.

A female client is surprised to learn that she has been diagnosed with hemochromatosis. Which of the following should the nurse respond to this client?

Maintain adequate nutrition.

A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient goal has the highest priority when the nurse is developing the plan of care?

cholecystitis.

A patient comes to the emergency department with the complaint of severe vomiting and nausea and a temperature elevation to 101 F. The patient complains of stomach pain that radiates to his right scapula. These assessments suggest:

anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patients illness, the nurse would expect serologic testing to reveal

Hepatitis A is not transmitted as a result of close contact with an infected individual.

A patient has reported to the clinic with concerns about contracting hepatitis A from her boyfriend. What response by the nurse is most appropriate?

Schedule the patient for HCV genotype testing.

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?

The patients stools are clay colored.

A patient is admitted to the hospital with acute cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider?

Do you use any over-the-counter (OTC) drugs?

A patient is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?

ambulate the patient to reduce gas.

A patient who had a laparoscopic cholecystectomy 4 hours ago complains of fullness in the abdomen and mild discomfort. Because his vital signs are stable, the nurse should:

The patient is alert and oriented.

A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that the medication is effective?

cancer of the gallbladder.

A patient who has had his fifth attack of gallstones is encouraged to have a cholecystectomy to prevent the threat of:

The medication will prevent irritation to the esophageal varices.

A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate?

Abdominal pain is decreased.

A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?

semen. breast milk human feces vaginal secretions.

The nurse points out to a patient recently diagnosed with hepatitis B virus (HBV) that the virus is found not only in blood but also in:

increased prothrombin time.

The nurse reading the laboratory reports for a patient with acute hepatitis is aware that an indicator supporting this diagnosis is:

liver

The nurse realizes that the organ which is a major site for metastases, harboring and growing cancerous cells that originated in some other part of the body, is the:

lifelong

The nurse reinforces that the immunization for HBV is believed to provide _____ immunity.

Pulmonary edema

The nurse, caring for a client recovering from the placement of a shunt to treat portal hypertension, should assess the client for which of the following complications associated with this surgery?

These enemas kill intestinal flora.

The physician has prescribed neomycin enemas for a patient with cirrhosis. The patient questions why they are being used. Which response by the nurse is most appropriate?

Ask the patient to extend both arms to the front.

To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take?

measures that will be helpful in improving appetite.

When a patient is diagnosed with acute hepatitis B, the nurse will plan to teach the patient about

Temperature 100.8 F (38.2 C)

When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider?

turn, cough, and deep breathe every 2 hours.

When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to

leukopenia

When combination therapy of a-interferon and ribavirin (Rebetol) is being used to treat chronic hepatitis C, the nurse will plan to monitor for

with every meal.

When educating a patient with chronic pancreatitis about the prescribed pancrelipase (Viokase), the nurse will teach the patient to take the medication

alcohol use.

When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of

Check the calcium level on the chart.

When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patients hand. Which action should the nurse take next?

giving lactulose.

When the liver is seriously damaged, ammonia levels can rise in the body. One of the treatments for this is:

Palpable abdominal mass

When the nurse is caring for a patient with acute pancreatitis, which assessment finding is of most concern?

Muscle twitching and finger numbness

Which assessment finding in a patient with acute pancreatitis would the nurse need to report most quickly to the health care provider?

The patients hands flap back and forth when the arms are extended.

Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?

The patient reports a one-time use of IV drugs 20 years ago.

Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done?

Administer prescribed opioids to relieve pain as needed.

Which nursing action is a priority when the nurse is caring for a patient with pancreatic cancer?

Review the patients current medication list.

Which nursing action will be included in the plan of care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

Monitor the patient for shortness of breath.

Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade?

Use a pressure-relieving mattress.

Which nursing action will be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs?

Providing oral hygiene before meals

Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate to nursing assistive personnel?

Amylase

Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis?

45-year-old with cirrhosis and severe ascites who has an oral temperature of 102 F (38.8 C)

. During change-of-shift report, the nurse learns about the following four patients. Which patient requires the most rapid assessment?

anti-HBs.

. The nurse determines that administration of hepatitis B vaccine to a patient has been effective when a specimen of the patients blood reveals

Hepatitis A

.A child care worker complains of flu-like symptoms. On further assessment, hepatitis is suspected. The nurse realizes that this individual is at risk for which type of hepatitis?

Low vitamin A levels Nerve damage Increased bleeding Poor digestion of fats Insulin resistance

.A client is diagnosed with a disorder of the liver. The nurse realizes this client might experience which of the following?

biliary atresia.

.A school age child is placed on a waiting list for a liver transplant. The nurse knows that the most common reason for children to need this type of transplant is because of:

Avoid all alcohol.

A client is diagnosed with macrovesicular fatty liver. Which of the following should the nurse instruct this client?

Esophageal varices Splenomegaly Hemorrhoids Caput medusae

A client is diagnosed with portal hypertension. The nurse should assess the client for which of the following disorders associated with this diagnosis?

Perforation of the stomach Perforated duodenum Pancreatitis Aspiration of gastric contents Anaphylactic reaction to the contrast dye

A client is recovering from an endoscopic retrograde cholangiopancreatogram (ERCP). Which of the following should the nurse assess as possible complications from this procedure?

an injection of hepatitis B immune globulin (HBIG).

A 20-year-old college student who has not been immunized against hepatitis B virus (HBV) comes to the clinic and reports that he has been exposed to hepatitis B. The nurse recommends that he get immediate protection by acquiring:

Need to abstain from alcohol

A 32-year-old patient is diagnosed with early alcoholic cirrhosis. Which topic is most important to include in patient teaching?

Diuretic therapy Fluid restriction Low-sodium diet

A client diagnosed with cirrhosis is experiencing the complication of ascites. Which of the following would be considered treatment for this complication?

Kernicterus Jaundice Icterus

A client is demonstrating yellow pigmentation of the skin and sclera. Which of the following can be used to describe this clients symptoms

Hyponatremia

A client is diagnosed with liver disease. Which of the following is one impact of this disorder on a clients fluid and electrolyte status?

insertion of a Blakemore-Sengstaken tube. lactulose to empty swallowed blood in colon. vasoconstrictors to reduced portal blood flow. administration of IV vasopressin (Pitressin).

A patient with advanced cirrhosis develops esophageal varices as a direct result of portal hypertension. The nurse anticipates that this complication will be addressed by:

Stools test negative for occult blood.

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which assessment finding is the best indicator that the medication has been effective?

decreasing the production of ammonia.

A patient with cirrhosis complains of the blandness of the low-protein diet and questions its effectiveness. The nurse reminds the patient that the low-protein diet helps his condition by:

albumin level.

A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patients

Check BP, heart rate, and respirations.

A patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first?

Administer the spironolactone.

A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take?

chest

A patient with esophageal varices is receiving potent vasoconstrictors to help prevent hemorrhage. The nurse will be concerned if the patient complains of pain in the:

ammonia levels.

A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor

Decrease in episodes of variceal bleeding

After a patient has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective?

Administer hepatitis B vaccine. Test for antibodies to hepatitis B. Give hepatitis B immune globulin.

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take

I can remove the bandages on my incisions tomorrow and take a shower.

After providing discharge instructions to a patient following a laparoscopic cholecystectomy, the nurse recognizes that teaching has been effective when the patient states,

drinking excessive alcohol.

An older male is diagnosed with cirrhosis of the liver. The nurse knows that the most likely cause of this problem is:

become vaccinated.

Because health care workers are at a greater risk of hepatitis B infection, it is recommended that all health care workers:

HAV HBV HCV HDV HEV

Fecal-oral transmission, acute onset Transmission by contact with blood and body fluids, perinatal transmission from mother to infant Most likely to lead to cirrhosis Coexists with HBV Prevalent in less developed countries

dark brown stool.

In a patient who had a cholecystectomy 3 days ago, the nurse assesses that the bile is no longer obstructed from entering the bowel by the appearance of:

Standard Precautions.

In caring for a patient with hepatitis B, the nurse would follow:

maintenance of normal respiratory function.

In planning care for a patient with acute severe pancreatitis, the nurse assigns the highest priority to the patient outcome of

asks the patient to empty the bladder.

The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse

confusion related to rising ammonia levels.

The nurse assesses that a patient with cirrhosis is deteriorating when there is evidence of:

indication of retroperitoneal hemorrhage.

The nurse caring for a patient with acute pancreatitis assesses a bluish tinge around the patients umbilicus. This finding is best reported as:

auscultation of bowel sounds to detect paralytic ileum. effectiveness of pain control. urine output. amount of food eaten each meal.

The nurse caring for a patient with acute pancreatitis will include in the daily assessments:

pruritus

The nurse explains that bile salts deposited in the skin cause jaundice and also cause

congestion in the liver obstructing bile flow.

The nurse explains that the jaundice observed in a person with hepatitis is related to the:

diagnose abnormal contraction of the gallbladder.

The nurse explains to a patient with cholelithiasis that the purpose of the cholescintigraphy (HIDA scan) is to:

liver biopsy.

The nurse is aware that a definitive diagnosis of cirrhosis is made based on the results of a(n):

Gallstones cause an irritation which is linked to an increase in the incidence of cancer.

The nurse is caring for a patient being treated for recurrent gallstones. The patient questions the need to have the stones removed, voicing a concern about the condition causing cancer. What statement by the nurse is most correct?

he is obese.

The nurse is caring for a patient diagnosed with gallstones. The patients medical record indicates the presence of two gallstones less than 1.5 inches. The patient is obese and has a history of insulin-dependent diabetes. The patient asks the nurse why he could not have a lithotripsy. The nurse points out that the criteria for the procedure are rigid and that he failed to meet them because:

Encouraging frequent rest periods

The nurse is caring for a patient diagnosed with hepatitis during the posticteric phase of the condition. When planning care, which intervention should be of the highest priority?

pegylated -interferon (PEG-Intron, Pegasys) SQ daily

The nurse is caring for a patient with chronic hepatitis C infection who has these medications prescribed. Which medication requires further discussion with the health care provider prior to administration?

portal hypertension. decrease in metabolic processes of the liver. decrease in clotting factors. increase in ascites.

The nurse is discussing the impact of cirrhosis on liver function with the family of a dying patient. The nurse explains that, when the damage caused by cirrhosis blocks the blood flow through the liver, the result is:

Avoid nectarines. Avoid liver. Avoid shellfish. Avoid mushrooms.

The nurse is providing dietary instruction to a client diagnosed with Wilsons disease. Which of the following should be included in these instructions?

Taking cholesterol-lowering drugs Obesity Diabetes Mexican American ethnicity

The nurse is speaking with a patient who has concerns about the development of cholelithiasis. The nurse correctly includes which risk factors for the condition?

bathing in tepid water. applying emollients to decrease itching. cutting the patients fingernails short. changing the patients position every 1 to 2 hours.

The nurse plans for the skin care of the patient with ascites, which would include: