321 Exam 3 - Ch 49: Assessment/Management of Pts with Hepatic Disorders

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

Which condition indicates an overdose of lactulose?

watery diarrhea

Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of health teaching, the nurse advises a group of women that the amount of daily alcohol use should be limited to the equivalent of:

2 6oz glasses of wine

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is:

acetaminophen

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?

ammonia

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

change in client's handwriting and/or cognitive performance

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis

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

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?

hemolytic

In what location would the nurse palpate for the liver?

right upper quadrant

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

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include?

how often do you drink alcohol

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

maintaining the airway

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

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

A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse?

silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated

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

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

pad side rails on bed

Which is the most common cause of esophageal varices?

portal HTN

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