AQ: Disorders of the Liver
A patient has an increased ammonia level associated with hepatic encephalopathy. What assessment finding does the nurse expect? A) Aphasia B) Asterixis C) Hyperactivity D) Acute dementia
B) Asterixis Rationale: Asterixis is a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy. Aphasia, hyperactivity, and acute dementia are manifestations not associated with hepatic encephalopathy. Besides asterixis, an increased serum ammonia level causes sedation and confusion that progress to a comatose state.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A) "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." B) "I need to take good care of my belly and ankle skin where it is swollen." C) "A scrotal support may be more comfortable when I have scrotal edema." D) "I can use pillows to support my head to help me breathe when I am in bed."
A) "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." Rationale: If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency.
A nurse is collecting data from a patient admitted with hepatitis A. Which information given by the patient may indicate the patient's susceptibility to contract hepatitis A? Select all that apply. A) Living in slums B) Working as local plumber C) Working in a chemical factory D) Working as a sewage cleaner E) Working as a waiter and dishwasher
A) Living in slums B) Working as local plumber D) Working as a sewage cleaner Rationale: Hepatitis A spreads mainly through the fecal-oral route. People living in slums are also exposed to the virus, because food stuffs may be contaminated. Sewage may harbor this virus; hence sewage cleaners and plumbers may be exposed to it. Working as a waiter, dishwasher, or in a chemical factory does not expose the patient to the virus.
What points should a nurse emphasize while teaching a patient ways to protect oneself from exposure to hepatitis B infection? Select all that apply. A) Use disposable needles and syringes. B) Avoid sharing toothbrushes and razors. C) Avoid eating food prepared in unhygienic ways. D) Avoid touching or coming in contact with people with hepatitis E) Avoid unsafe sex with multiple partners, and always use condoms.
A) Use disposable needles and syringes. B) Avoid sharing toothbrushes and razors. E) Avoid unsafe sex with multiple partners, and always use condoms. Rationale: Hepatitis B spreads through sexual contact and through blood. Sharing razors or toothbrushes with an infected person may introduce infection in another person's body. Similarly, a needle used by an infected person can spread the infection. Hepatitis B also spreads via sexual exposure with an infected person. Using a condom gives some protection against the spread of infection. Hepatitis B doesn't spread through water and food. Hepatitis B doesn't spread with general casual contact.
What are the clinical manifestations of chronic hepatitis? Select all that apply. A) Bilirubinuria B) Hepatomegaly C) Nausea and vomiting D) Elevated liver enzymes E) Decreased sense of taste
B) Hepatomegaly D) Elevated liver enzymes Rationale: Chronic hepatitis is manifested by hepatomegaly and elevated liver enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Bilirubinuria, nausea, vomiting, and decreased sense of taste are associated with acute hepatitis.
Assessment findings of a patient include asterixis, hyperventilation, fetor hepaticus, fatigue, a body temperature of 95° F, and continuous lip smacking. Which condition does the nurse suspect? A) Hepatitis B) Liver cirrhosis C) Hepatorenal syndrome D) Hepatic encephalopathy
D) Hepatic encephalopathy Rationale: Hepatic encephalopathy is a mental disorder that occurs due to acute or chronic liver injury. Hypothermia, grimacing reflexes (actions like lip smacking and lip puckering), fatigue, asterixis, hyperventilation, and fetor hepaticus are the clinical manifestations of hepatic encephalopathy. Hepatitis is an inflammatory condition of the liver, characterized by anorexia, nausea, vomiting, and fever. Liver cirrhosis is a liver disease manifested by symptoms ranging from portal hypertension to liver failure. Hepatorenal syndrome occurs in patients with decompensated liver cirrhosis and can lead to renal failure.
A patient with cirrhosis of the liver has ascites and is being prepared for a paracentesis. What instructions should the nurse give the patient? A) The patient should fast overnight. B) The patient should not pass urine until the procedure. C) The patient should not take any fluids before the procedure. D) The patient should void urine immediately before the paracentesis.
D) The patient should void urine immediately before the paracentesis. Rationale: The nurse should instruct the patient to void prior to the paracentesis to prevent accidental puncture of the bladder. During the procedure, the patient sits on the side of the bed or is placed in high Fowler's position. There is no need to keep the patient on NPO status (taking nothing by mouth) or to restrict fluid intake.
The nurse finds that a patient admitted to the hospital with cirrhosis of the liver is disoriented, lethargic, and drowsy and has abnormal reflexes. Based on the patient's signs and symptoms, the nurse understands that the patient is in grade ___ hepatic encephalopathy. Fill in the blank using a whole number.
2 Hepatic encephalopathy has grades 0 to 4 based on three factors: level of consciousness, intellectual function, and neurologic findings. Grade 2 is characterized by lethargy, drowsiness, and inappropriate behavior (level of consciousness); disorientation (intellectual function); and asterixis and abnormal reflexes (neurologic findings). Grade 1 is characterized by a short attention span, mild confusion, and depression. Grade 3 is characterized by loss of meaningful conversation, marked confusion, and incomprehensible speech. Grade 4 is characterized by a complete lack of intellectual function. Grade 0 is characterized by insomnia, sleep disturbances, and a subtle change in computational skills.
A patient with a chronic hepatitis C virus (HCV) infection is admitted to the hospital. What are the factors that contribute to a high risk for development of cirrhosis of the liver in this patient? Select all that apply. A) Diabetes mellitus B) Alcohol consumption C) History of regular smoking D) Elevated levels of cholesterol E) Diet high in sodium and fatty foods
A) Diabetes mellitus B) Alcohol consumption D) D) Elevated levels of cholesterol Rationale: Hepatitis C virus (HCV) infection is more likely than hepatitis B virus (HBV) to become chronic. An infection with HCV can lead to development of cirrhosis of the liver. People with diabetes mellitus have a compromised immune function and are at risk of developing cirrhosis. Alcohol consumption may further deteriorate the liver function and lead to development of cirrhosis of the liver. Elevated cholesterol or triglycerides suppresses liver function and may lead to progression of HCV to cirrhosis. Smoking and a high-sodium diet have no effect on hepatitis C progression because they do not affect liver function.
A patient with cirrhosis of the liver is admitted to the hospital. What complications of cirrhosis is the nurse likely to find in the patient? Select all that apply. A) Edema of the feet B) Difficulty breathing C) Disorientation and lethargy D) Blood in the stools or black stools E) Severe pain in the chest with a cold sweat
A) Edema of the feet C) Disorientation and lethargy D) Blood in the stools or black stools Rationale: Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Gastric varices bleed easily. This bleeding can be presented as blood in vomiting or blood in the stool. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbances, and lethargy. Cirrhosis doesn't lead to pain in the chest with a cold sweat or difficulty in breathing.
A patient has just undergone a liver transplant and is now in the intensive care unit (ICU). What nursing interventions are appropriate for this patient to prevent respiratory complications? Select all that apply. A) Encourage the patient to cough. B) Consider repositioning the patient. C) Instruct the patient to walk around the bed D) Encourage the patient to take deep breaths. E) Administer cough suppressants to prevent coughing.
A) Encourage the patient to cough. B) Consider repositioning the patient. D) Encourage the patient to take deep breaths. Rationale: The patient who has had a liver transplant requires highly skilled nursing care in an ICU or another specialized unit. To prevent respiratory complications, the patient should be encouraged to use measures such as coughing, deep breathing, and repositioning. Administering cough suppressants would be counterproductive to recovery. The patient can be ambulated later, when the condition is stable.
A patient reports vomiting, nausea, and joint pain. An IgM antibody test has been prescribed. The nurse suspects what diagnosis? A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D
A) Hepatitis A Rationale: Hepatitis A is associated with nausea, vomiting, weight loss, and joint pain. When an individual is infected with the hepatitis A virus, the body produces the hepatitis A antibody immunoglobulin M (IgM). Because the primary health care provider prescribes an IgM antibody test, the nurse suspects that the patient has hepatitis A infection. Hepatitis B is diagnosed by performing anti-HBc IgG and anti-HBe tests. Anti-HCV, HCV genotyping, and HCV RNA quantification are performed to rule out hepatitis C. Hepatitis D is confirmed by performing anti-HDV and HDV antigen tests.
An elderly woman reports weakness, abdominal pain, and bleeding from the vagina. When reviewing the patient's diagnostic test reports, the nurse notes anemia and an enlarged spleen. The nurse suspects that the patient has what condition? A) Liver cirrhosis B) Pancreatic cancer C) Acute liver failure D) Acute pancreatitis
A) Liver cirrhosis Rationale: Liver cirrhosis is clinically manifested by skin lesions and enlarged spleen, resulting in hematologic changes such as thrombocytopenia, leukopenia, and anemia. It is associated with endocrine problems such as vaginal bleeding in elderly women and gynecomastia in males. Anorexia, dull and aching abdominal pain, progressive weight loss, and jaundice are the characteristics of pancreatic cancer. Acute liver failure is associated with jaundice, encephalopathy, and coagulation abnormalities. Acute pancreatitis is manifested by abdominal pain that radiates to the back; dyspnea, flushing, and cyanosis may accompany the pain.
A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? A) Milk thistle may affect liver enzymes and thus alter drug metabolism. B) Milk thistle generally is safe in recommended doses for up to 10 years. C) There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D) Milk thistle may elevate the serum glucose levels and thus is contraindicated in diabetes.
A) Milk thistle may affect liver enzymes and thus alter drug metabolism. Rationale: Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
Patient/Findings Patient A/Small, dilated blood vessels with bright red center point Patient B/Rapid flexion and extension movements of the hands Patient C/Musty, sweet odor of the breath Patient D/Bluish flank discoloration The nurse collects data on a group of patients and suspects that which patient has cirrhosis? A) Patient A B) Patient B C) Patient C D) Patient D
A) Patient A rationale: Small, dilated blood vessels with a bright red center point and spider-like branches around them indicate spider angioma, one of the clinical manifestations of cirrhosis, so Patient A is correct. Inability to stretch the hands, instead performing a series of rapid flexion and extension movements of the hands, indicates asterixis, the characteristic clinical manifestation of hepatic encephalopathy, for Patient B. Fetor hepaticus, a musty and sweet odor of the patient's breath, is a clinical manifestation of hepatic encephalopathy, for Patient C. Acute pancreatitis is associated with bluish discoloration of the flanks, for Patient D.
The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons? Select all that apply. A) There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B) Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C) Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D) Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E) Overactivity of the enlarged spleen results in increased removal of blood cells from circulation, which decreases vascular pressure.
A) There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B) Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C) Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Rationale: Ascites related to cirrhosis is caused by decreased colloid oncotic pressure from the lack of albumin due to the liver's inability to synthesize it and the portal hypertension that shifts protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism, which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not contribute directly to ascites.
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply. A) Use smallest gauge needle possible when giving injections or drawing blood B) Tech patient to avoid straining at stool, vigorous blowing of nose, and coughing C) Advise patient to uses soft-briskly toothbrush and avoid ingestion of irritating food D) Apply gentle pressure for the shortest possible time period after performing venipuncture E) Instruct patient to avoid aspirin and non-steroidal anti-inflammatory drugs (NSAIDS) to prevent hemorrhage when varies are present
A) Use the smallest gauge needle possible when giving injection or drawing blood B) Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing C) Advise patient to use soft-bristle toothbrush and avoid ingest of irritating food E) Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varies are present Rationale: Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. Aspirin and NSAIDS should be avoided because they can increase bleeding in ruptured varices. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.
What are the precautions that nurses and hospital staff should follow while handling patients suffering from hepatitis infections? Select all that apply. A) The patient must be in a private room, and door should be closed. B) Dispose of the needles and syringes used on the patient carefully. C) Wear gloves while handling articles contaminated by urine or feces. D) Always wear a mask, gown, and gloves when entering the patient's room. E) Follow infection control precautions while injecting the patient, and avoid getting pricked by the used needle.
B) Dispose of the needles and syringes used on the patient carefully. C) Wear gloves while handling articles contaminated by urine or feces. E) Follow infection control precautions while injecting the patient, and avoid getting pricked by the used needle. Rationale: Hepatitis A spreads through the fecal-oral route, and hepatitis B spreads through blood. Hence the virus can spread through needles and syringes used by the patient. Also, the virus can spread while the nurse is handling the urine or fecal material of the patient; hence it is necessary to wear gloves. Hepatitis does not spread through air; hence a mask is not required. A private room is required in respiratory diseases, not in hepatitis.
A patient suffering from ascites is admitted to the hospital. What are the factors that can lead to ascites development? Select all that apply. A) Diabetes mellitus B) Portal hypertension C) Hyperaldosteronism D) Decreased flow of hepatic lymph E) Decreased serum colloidal oncotic pressure
B) Portal hypertension C) Hyperaldosteronism E) E) Decreased serum colloidal oncotic pressure
A female patient expresses her concern about becoming pregnant while her partner is on ribavirin therapy for chronic hepatitis C. What should the nurse advise the patient? A) She can plan pregnancy now. B) She should avoid getting pregnant now. C) She should not get pregnant with this partner ever. D) She should avoid any sexual intercourse after conception.
B) She should avoid getting pregnant now. Rationale: Any woman who is on ribavirin or whose male partner is on is on ribavirin should avoid pregnancy during treatment. The pregnancy can be planned after the treatment is complete. She can get pregnant with this partner, but not while on treatment. Avoiding intercourse after conception is not necessary.
A patient reports loss of appetite, nausea, and vomiting. Laboratory test results reveal darkened urine and a positive hepatitis C antibody test. Which medication does the nurse anticipate will be prescribed? A) Adefovir B) Simeprevir C) Tenofovir D) Entecavir
B) Simeprevir Rationale: Fatigue, loss of appetite, nausea, and vomiting are the clinical manifestations of hepatitis. A positive report for the HCV antibody confirms hepatitis C infection. Simeprevir is a protease inhibitor and is effective in the treatment of hepatitis C. Adefovir, tenofovir, and entecavir belong to the class of nucleoside and nucleotide analogs and are used in the treatment of hepatitis B infection.
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? A) The patient has completed a college education. B) The chest x-ray showed another lung cancer lesion. C) The patient has been able to stop smoking cigarettes. D) The patient has well controlled type 1 diabetes mellitus.
B) The chest x-ray showed another lung cancer lesion. Rationale: Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course. It does not matter if the patient has a college education. The fact that the patient has quit smoking is not a contraindication for liver transplant. The patient is a well-controlled diabetic, which is not a contraindication.
The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? A) Cardiac output B) Blood pressure C) Abdominal girth D) Intake and outpu
C) Abdominal girth Rationale: Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the health care provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continue to be monitored to account for the paracentesis fluid, but these are not as informative as abdominal girth.
A patient with acute hepatitis B will be discharged tomorrow. The nurse should include which measures in the discharge teaching plan? Select all that apply. A) Restrict fluid intake. B) Avoid alcohol for the first three weeks. C) Avoid foods that are very hot or very cold. D) Be sure to allow for periods of rest during the day. E) Participate in an exercise regimen to build stamina. F) Eat small meals frequently rather than three times a day.
C) Avoid foods that are very hot or very cold. D) Be sure to allow for periods of rest during the day. F) F) Eat small meals frequently rather than three times a day. Rationale: Several measures are important for ensuring that the patient with hepatitis receives adequate nutrition. The anorexia and distaste for food cause nutritional problems. Assess the patient's tolerance of specific foods and eating patterns. Small, frequent meals may be preferable to three large ones and also may help prevent nausea. Measures to stimulate the appetite, such as mouth care, antiemetics, and attractively served meals in pleasant surroundings, should be included in the nursing care plan. Drinking carbonated beverages and avoiding very hot or very cold foods may help alleviate anorexia. Rest is an important factor in promoting hepatocyte regeneration. Assess the patient's response to the rest and activity plan, and modify it accordingly. Adequate fluid intake (2500 to 3000 mL/day) is important. Restricting fluid intake and participating in exercise regimens are not appropriate measures. Patients with hepatitis need to avoid alcoholic beverages.
A patient with type 2 diabetes mellitus has been diagnosed with non-alcoholic fatty liver disease (NAFLD). The nursing teaching plan should include which of the following? A) Having genetic testing done B) Eliminating carbohydrates from the diet C) Following measures to gain tighter glucose control D) Avoiding alcohol until liver enzymes return to normal
C) Following measures to gain tighter glucose control Rationale: NAFLD can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For those who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. NAFLD does not show up positive on a genetic test. It is not recommended to completely eliminate carbohydrates from the diet. NAFLD is not caused by alcohol, and the question does not imply that the patient drinks.
A nurse is caring for a patient with cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination? Select all that apply. A) White patches on skin B) Deposits of dark pigments C) Small areas of bleeding into the skin D) Vascular lesions formed by small blood vessels E) Small dilated blood vessels with spider like branches
C) Small areas of bleeding D) Vascular lesions formed by small blood vessels E) Small dilated blood vessels with spider like branches Rationale: Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis.
A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? A) Decrease fluid intake to avoid ascites. B) Eat foods quickly so they do not get cold and cause distress. C) Avoid exercise because it may cause bleeding of the varices. D) Avoid straining during defecation to keep venous pressure low.
D) Avoid straining during defecation to keep venous pressure low. Rationale: Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid, and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation.
The health care provider prescribes lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A) Relief of constipation B) Relief of abdominal pain C) Decreased liver enzymes D) Decreased ammonia levels
D) Decreased ammonia levels Rationale: Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. Lactulose does not relieve constipation or abdominal pain or decrease liver enzymes.
The nurse cares for a patient with advanced cirrhosis. What indicates that the patient is experiencing a serious complication? A) Urine retention B) Increased blood glucose C) No bowel movement in three days D) Frequent nosebleeds and bruising
D) Frequent nosebleeds and bruising Rationale: The liver produces clotting factors. As cirrhosis becomes more advanced, the production of clotting factors is disrupted and thereby decreased, making the patient more susceptible to bleeding. Increasing frequency and severity of nosebleeds and bruising would indicate a deterioration in liver function. Urine retention, abnormal blood glucose, and constipation are not directly associated with advanced cirrhosis.
