TERM 4 1 Ch 58 Care of Patients with Liver Problems
A client with ascites says, "This diet is terrible. I don't know how anyone can survive with no salt on their food." What is the best response by the nurse? 1 "You can add just one teaspoon of salt to your food each day." 2 "This is a terribly restrictive diet, but you must adhere to it." 3 "Not eating salt is an acquired taste, which you can become used to." 4 "Adding salt to your food will make you more confused than you already are."
"Not eating salt is an acquired taste, which you can become used to." Table salt should be completely excluded from the diet. The client should be made aware that humans are not born craving salt, so in time, the client can become used to a low-sodium diet. Agreeing the diet is restrictive does not help promote adherence nor offer hope to the client that the situation can improve. While it is true that adding sodium will promote fluid retention and worsen ascites, it is not a cause of encephalopathy/confusion.
A client with long-standing alcoholic liver disease has a decrease in serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) from previously assessed levels. What does the nurse tell the client about these results? 1 "These results indicate improvement." 2 "These decreases may indicate liver deterioration." 3 "These results indicate depletion of AST and ALT enzymes." 4 "These decreases usually occur when osteoporosis is present."
"These decreases may indicate liver deterioration." AST and ALT are elevated because these enzymes are released into the blood during liver inflammation. As the liver deteriorates, however, the hepatocytes become unable to initiate an inflammatory response and cannot release these enzymes, so the levels decline. In a client with acute liver disease, a decline in these levels may indicate improvement, but not in a client whose disease is long-standing and chronic. The levels drop because they are not produced, not because they are depleted. Osteoporosis causes an increase in alkaline phosphatase.
A client is admitted with bleeding esophageal varices. The nurse anticipates which factors may be included in the client's plan of care? Select all that apply. 1 Liver biopsy 2 Frequent vital signs 3 Antiplatelet medication 4 Red blood cell transfusion 5 Sengstaken-Blakemore tube 6 Beta-adrenergic blocking agent
-Frequent vital signs -Red blood cell transfusion -Sengstaken-Blakemore tube -Beta-adrenergic blocking agent Frequent vital signs are necessary during bleeding episodes to assess for shock and evaluate therapies. Red blood cells are given to replace fluid volume and oxygen-carrying capacity lost during hemorrhage. Esophageal balloon tamponade with a Minnesota or Sengstaken-Blakemore tube is used to control bleeding through direct pressure. Beta-adrenergic blockers are used to reduce portal pressure and therefore bleeding. Platelets, rather than antiplatelet medications which can cause bleeding, are usually administered. A liver biopsy is done to diagnose the cause of the cirrhotic process, but it is not a treatment for bleeding esophageal varices.
When assessing a client with hepatitis B, the nurse anticipates which assessment findings? Select all that apply. 1 Recent influenza infection 2 Brown stool 3 Tea-colored urine 4 Right upper quadrant tenderness 5 Itching
-Tea-colored urine -Right upper quadrant tenderness -Itching The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.
When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? 1 Hemoglobin and hematocrit 2 Leukocytes 3 Alpha-fetoprotein 4 Serum albumin
Alpha-fetoprotein Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.
A client with Laennec's cirrhosis has an increased abdominal girth of 12 cm over the measured abdominal girth from a previous admission. Which condition does the nurse suspect in this client? 1 Ascites 2 Esophageal varices 3 Hepatomegaly 4 Splenomegaly
Ascites Clients with ascites have fluid in the peritoneal cavity, causing abdominal distention. A client with an increase in abdominal girth should be evaluated for ascites. Esophageal varices are characterized by distention of esophageal vessels with increased risk for bleeding. Hepatomegaly is liver enlargement. Splenomegaly is spleen enlargement.
In discussing long-term care needs with a client with alcoholic cirrhosis, the client tells the nurse that long-term abstinence from alcohol seems impossible and asks if small amounts of alcohol may be tolerated. Which nursing action is correct? 1 Ask the client to identify a person who can be supportive during alcohol withdrawal. 2 Enlist the help of a family member to remove alcohol from the client's home. 3 Suggest that the client discuss safe amounts of alcohol with the provider. 4 Tell the client that any alcohol intake may cause a fatal progression of the disease.
Ask the client to identify a person who can be supportive during alcohol withdrawal. If alcohol is the cause of cirrhosis, abstinence from alcohol is essential. The client who feels hopeless should be steered towards a support group or person who can be helpful and supportive. Asking a family member to remove alcohol from the home and reminding the client that consumption of alcohol may be fatal do not address the problem of hopelessness.
The nurse is assessing diagnostic test results for a client with hepatitis. Which elevated test result does the nurse correlate to the presence of jaundice? 1 Bilirubin 2 Blood urea nitrogen (BUN) 3 Aspartate aminotransferase (AST) 4 Alanine aminotransferase (ALT)
Bilirubin Elevation of the bilirubin level correlates to yellow stain of the skin and sclera secondary to biliary obstruction and inflammation. BUN is a measure of renal function. AST and ALT are enzymes released in response to liver inflammation, but do not correlate to jaundice.
It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? 1 Right shoulder pain 2 Polyuria 3 Bone marrow suppression 4 Bleeding
Bleeding When monitoring a client post-hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority. Discomfort may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.
A client with liver disease has portal hypertension. Which clinical finding prompts the nurse to notify the provider immediately? 1 Blood pressure of 145/95 mm Hg 2 Blood-tinged emesis 3 Liver distention 4 Urine output of 200 mL/hr
Blood-tinged emesis Clients with portal hypertension are at risk for hemorrhage and should be monitored closely; blood-tinged emesis may indicate bleeding esophageal varices and should be reported immediately. A moderate elevation in blood pressure and liver distention are common, nonemergent findings in clients with liver disease. A urine output of 200 mL/hr does not need to be reported because normal urine output is 1500-2000 mL per day.
A client who was previously treated for hepatitis B virus (HBV) is tested for the presence of the hepatitis B surface antigen (HBsAg) in the blood. The test is positive. What does this result indicate? 1 Permanent immunity to HBV 2 Recurrence of infection 3 Long-term liver damage 4 Client is infectious
Client is infectious As long as the HBsAg is present, the client is infectious and may be in a carrier state. It does not indicate permanent immunity, recurrence of infection, or long-term liver damage.
In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? 1 Increased blood pressure, increased respiratory rate 2 Decreased blood pressure, increased heart rate 3 Increased respiratory rate, increased apical pulse, pallor 4 Tachypnea, diaphoresis, increased blood pressure
Decreased blood pressure, increased heart rate Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.
Which assessment finding is consistent with a diagnosis of viral hepatitis? 1 Icteric skin 2 Dark-brown stool 3 Light-colored urine 4 Left upper quadrant tenderness
Icteric skin Findings in viral hepatitis include fever, jaundice or icterus, itching, clay-colored stool, dark urine, right upper quadrant tenderness, and nausea.
The nurse is caring for a client with cirrhosis and profound ascites. Which assessment finding causes the nurse to notify the provider? 1 Anasarca 2 Marked jaundice 3 Multiple ecchymoses 4 Inaudible breath sounds
Inaudible breath sounds Orthopnea and dyspnea can result from ascites, which limit thoracic expansion and diaphragmatic excursion; this is manifested by decreased or absent breath sounds. Anasarca is an expected finding in cirrhosis as the liver is unable to produce plasma proteins which exert colloid osmotic pressure to pull fluid from interstitial tissues. Jaundice, another expected finding, results when the failing liver cannot excrete bilirubin. Ecchymosis is typical when the client with cirrhosis cannot produce prothrombin, which promotes blood clotting.
A client with viral hepatitis has clay-colored stools and dark urine. These findings are typically characteristic of which complication of hepatitis? 1 Cirrhosis of the liver 2 Hepatic carcinoma 3 Intrahepatic obstruction 4 Obstructive jaundice
Intrahepatic obstruction Clients with hepatitis may develop intrahepatic obstruction, which will cause clay-colored stools and dark urine when the bile ducts are blocked. These findings may occur with hepatic obstruction in cirrhosis or carcinoma, but do not necessarily indicate that these have occurred. Obstructive jaundice is another sign of intrahepatic obstruction.
A client with refractory ascites has a tunneled ascites drain (PleurX catheter). The community health nurse teaches the client and family which most important aspect of care while this device is in place? 1 Remaining on bedrest 2 Keeping hands and the area clean 3 Observing for diminished urine output 4 Learning to take blood pressure each day
Keeping hands and the area clean Clients with an indwelling device are prone to infection. Clients with ascites may also develop spontaneous bacterial peritonitis. Therefore, hands should always be cleansed before touching the area or using the device. Bedrest is necessary after a procedure such as paracentesis, but is not necessary while the drainage device is in place. Diminished urine output and a lower blood pressure are typically present with hepatic failure and ascites because fluid is third-spaced. Blood pressure may also drop with bleeding varices; however, daily monitoring is not needed with the ascites drainage device.
When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? 1 Kidney failure 2 Refractory ascites 3 Fetor hepaticus 4 Paracentesis scheduled for today
Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.
The nurse teaches a client with hepatic encephalopathy that certain food should be consumed in moderation while the client's serum ammonia level is elevated. Which food does the nurse instruct the client to limit? 1 Pasta 2 Rice 3 Lean meats 4 Vegetables
Lean meats The diet for those who have elevated serum ammonia levels with signs of encephalopathy includes moderate amounts of protein and fat along with simple carbohydrates. Strict protein restrictions are not required because clients need protein for healing. Pasta, rice, and vegetables are carbohydrates that are included in the diet for energy.
When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? 1 Clients who work with shellfish 2 Men who prefer sex with men 3 Clients traveling to a third-world country 4 Clients with elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
Men who prefer sex with men Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.
When assessing a client for possible liver dysfunction, the nurse notices round, pinpoint, red-purple lesions on the client's skin. What term is used to document such lesions? 1 Ecchymosis 2 Telangiectases 3 Petechiae 4 Spider angioma
Petechiae The term petechiae is used for round, pinpoint, red-purple lesions. Ecchymoses are large purple, blue, or yellow patches. Telangiectases and spider angioma are terms used for vascular lesions with a red center and radiating branches.
What type of cirrhosis is caused by hepatitis C? 1 Postnecrotic 2 Laennec's 3 Biliary 4 Cholestatic
Postnecrotic The hepatitis C virus causes postnecrotic cirrhosis. Laennec's cirrhosis is caused by chronic alcoholism. Biliary cirrhosis is also called cholestatic cirrhosis; it is caused by chronic biliary obstruction or autoimmune disease.
The nurse is administering spironolactone (Aldactone) to a client with portal hypertension and portal systemic encephalopathy. Which additional medication order does the nurse question? 1 Potassium chloride 2 Lactulose (Cephulac) 3 Neomycin (Mycifradin) 4 Propranolol (Inderal)
Potassium chloride Spironolactone is a potassium-sparing diuretic; additional potassium may result in potassium intoxication. Cephulac and neomycin are used to control hepatic encephalopathy, which is part of the expected treatment plan. Propranolol is used to prevent gastrointestinal hemorrhage secondary to portal hypertension and gastroesophageal varices, which is an expected treatment for portal hypertension.
Which problem for a client with cirrhosis takes priority? 1 Insufficient knowledge related to the prognosis of the disease process 2 Discomfort related to the progression of the disease process 3 Potential for injury related to hemorrhage 4 Inadequate nutrition related to an inability to tolerate usual dietary intake
Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.
What is a feature of hepatic abscess? 1 Symptoms of amebic hepatic abscess are usually sudden. 2 Mortality rates of hepatic abscesses are low. 3 Multiple hepatic abscesses are often found simultaneously. 4 Right upper abdominal pain is a common manifestation.
Right upper abdominal pain is a common manifestation. One of the common manifestations of a hepatic abscess is right upper abdominal pain. Symptoms of amebic hepatic abscess develop slowly. The mortality or death rate due to hepatic abscess is usually high. Both pyogenic and amebic hepatic abscesses are usually solitary. There may occasionally be multiple pyogenic abscesses in the same person.
A client with hepatic encephalopathy may require which dietary or pharmacologic therapy to help decrease serum ammonia levels? 1 Diet high in carbohydrates and protein with moderate fats 2 Diet low in protein and moderate in fats and carbohydrates 3 Trial of lactulose to increase the excretion of ammonia 4 Nonabsorbable antibiotics given for long-term therapy
Trial of lactulose to increase the excretion of ammonia Lactulose can be used with hepatic encephalopathy to increase the excretion of ammonia through the stools. To help minimize serum ammonia, clients may be started on a moderate protein, fat, and carbohydrate diet. High protein increases ammonia and low protein does not provide enough protein for healing. Nonabsorbable antibiotics may be used, but are given short-term only.
A client diagnosed with hepatitis A asks the nurse how this disease may have been contracted. Which answer by the nurse is correct? 1 "If you received a blood transfusion, you may have been exposed." 2 "The virus is airborne, so you may have contracted it from an infected person." 3 "You may have been exposed if you had unprotected sexual intercourse." 4 "You may have consumed foods contaminated with the virus."
"You may have consumed foods contaminated with the virus." Hepatitis A is transmitted through the fecal-oral route and may be contracted by consuming contaminated foods; it is not a blood-borne or airborne virus. Hepatitis B, C, and D can be transmitted by blood transfusions received before 1992. Unprotected sex is a risk factor for hepatitis B and C (although the rate of sexual transmission with hepatitis C is very low in a monogamous relationship, but increases with multiple sex partners). There is no hepatitis virus that is airborne.
When teaching a client with viral hepatitis, which instructions does the nurse include in the plan of care? Select all that apply. 1 Do not consume any alcohol. 2 Consume a high-protein diet. 3 Do not drive a car for 1-2 weeks. 4 Monitor blood pressure and pulse daily. 5 Avoid medications containing acetaminophen. 6 Avoid carbonated beverages.
-Do not consume any alcohol. -Avoid medications containing acetaminophen. The client with hepatitis should avoid all alcohol as well as hepatotoxic medications such as acetaminophen unless instructed otherwise by the provider. The diet should be high in carbohydrates with moderate fat and moderate protein content. The client may drive if he or she feels well. As hepatitis does not directly affect the cardiovascular system, there is no need to monitor vital signs. While carbonated beverages may contribute to a sense of fullness, it is not required that they be absolutely excluded.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? 1 Client with hepatitis A reporting severe and ongoing itching 2 Client with severe ascites who has a temperature of 101.4° F (38° C) 3 Client with cirrhosis who has had a 3-pound weight gain over 2 days 4 Client with esophageal varices and mild right upper quadrant pain
Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.
The community health nurse is exploring the cause of an outbreak of hepatitis A. Which individual does the nurse suspect may be the source? 1 Individual who recently got a tattoo 2 Clients who were infected after eating at the same restaurant 3 Spouse of an intravenous drug abuser who developed hepatitis 4 Client who had a blood transfusion during cardiac surgery in 1985
Clients who were infected after eating at the same restaurant Hepatitis A is spread by the fecal-oral route either by person-to-person contact, or by consuming contaminated food or water; failure to clean the hands after using the toilet and then preparing food is an example of how hepatitis can be spread by this route. Tattoos, injection drug use, and blood transfusions can spread hepatitis B or C through blood or body fluids.
A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? 1 Colon cancer with metastasis to the liver 2 Hypertension 3 Hepatic encephalopathy 4 Ascites and shortness of breath (SOB)
Colon cancer with metastasis to the liver Transplantation is performed for hepatitis and primary (not secondary) liver cancers. Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation; they can be managed with diuretics and paracentesis.
Which diet instruction does the nurse give to a client with active hepatitis? 1 Consume soft, easy-to-chew foods. 2 Follow a low-protein, low-fat diet. 3 Eat a normal diet with fluid restrictions. 4 Eat small meals at frequent intervals.
Eat small meals at frequent intervals. Small, frequent meals are often preferable to three standard meals for the client with hepatitis because these clients often experience nausea and vomiting and dietary intolerance. Soft, easy-to-chew foods are used with clients who have problems with dentition/chewing. The diet of the client with hepatitis should be high in carbohydrates and calories with moderate amounts of fat and protein after nausea and anorexia subside; clients with liver disease should limit fat in the diet due to intolerance. Fluid restriction is only recommended in clients with severe ascites and anasarca.
Which instruction is essential for the nurse to include when teaching a client who is undergoing treatment for hepatitis with ribavirin? 1 Never miss a dose. 2 Avoid going out in the sun. 3 Take the medication on an empty stomach. 4 Take the medication at the same time each day.
Never miss a dose. Clients being treated with Ribavirin for hepatitis C are instructed to never miss a dose of the drug. The nurse should assist the client in methods to use for reminders such as setting an alarm or alert. Exposure to sun is not contraindicated with ribavirin; this restriction pertains to sulfonamides or antipsychotic medications. This medication is often taken with food.
When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? 1 Vitamin K-containing products 2 Potassium-sparing diuretics 3 Nonabsorbable antibiotics 4 Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.
A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? 1 Obtain the charts from the previous admission. 2 Listen for bowel sounds in all quadrants. 3 Obtain pulse and blood pressure. 4 Ask about abdominal pain.
Obtain pulse and blood pressure. The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized. Assessment for adequate perfusion is the highest priority at this time.
A client with severe cirrhosis of the liver has a urine output of 400 mL for the past 2 days despite adequate intravenous fluid administration. What is the priority nursing action for this client? 1 Contact the provider to discuss obtaining a urine culture. 2 Encourage the client to increase oral fluid intake. 3 Perform a bladder scan to assess for urinary retention. 4 Request an order for blood urea nitrogen (BUN) and serum creatinine levels.
Request an order for blood urea nitrogen (BUN) and serum creatinine levels. Clients with cirrhosis may develop hepatorenal syndrome (HRS), which is characterized by oliguria less than 500 mL/day and elevated BUN and creatinine levels. The nurse should request these additional tests to help determine this. Decreased urine output is not a sign of urinary tract infection (UTI), so a culture is not indicated. The client has been receiving adequate fluids, so additional intake is not indicated. If BUN and creatinine levels are normal, assessing for retention may then be warranted.
