Assessment and Management of Patients With Hepatic Disorders

After a liver transplant, evidence-based guidelines are implemented to prevent the development of what? A) VAP B) ESLD C) MELD D) OLT

ANS: A Evidence-based practice guidelines are implemented to prevent the development of VAP in the postoperative liver transplant recipient. ESLD means end-stage liver disease; MELD is model of end-stage liver disease; orthotopic liver transplantation is OLT.

A patient with esophageal varices has medication ordered to decrease portal pressure and aid in preventing a first bleeding episode. What type of drug would the physician order? A) Antihypertensive agents B) Beta-blocking agents C) Calcium channel blockers D) Histamine-2 antagonists

ANS: B Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in patients with known varices and to prevent rebleeding. This makes options A, C, and D incorrect.

A critical care nurse is caring for a patient post liver transplantation. The patient has a fall in blood glucose level. What would the nurse do in this instance? A) Give an ampule of D50 every 4 hours B) Monitor an infusion of 5% glucose for the first 24 hours C) Monitor an infusion of 10% glucose for the first 48 hours D) Give an ampule of D50 every 2 hours

ANS: C Metabolic abnormalities require careful attention. A constant infusion of 10% glucose may be required in the first 48 hours to prevent a precipitous fall in the blood glucose level that results from decreased gluconeogenesis. Options A, B, and D are incorrect.

Postnectrotic cirrhosis is a late result of what? A) Acute bacterial hepatitis B) Hemolytic jaundice C) Acute viral hepatitis D) Chronic biliary obstruction

ANS: C Postnecrotic cirrhosis, in which there are broad bands of scar tissue, is a late result of a previous bout of acute viral hepatitis. Therefore options A, B, and D are incorrect.

The nursing instructor is teaching the beginning nursing students how to palpate a liver. What technique will the student nurse use to palpate a patient's liver? A) Place hand under left lower rib cage and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to abdomen and push down firmly.

ANS: C To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. Therefore options A, B, and D are incorrect.

A patient is being discharged home after liver transplantation. The patient still has a hepatic artery catheter in place. What is this hepatic artery catheter for? A) To monitor portal hypertension B) To give immunosuppressive drugs during the first weeks after transplantation C) To monitor vascular changes in the hepatic system D) To deliver a continuous chemotherapeutic dose until completed

ANS: D In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.

What liver function test is a sensitive indicator of injury to liver cells and useful in detecting acute liver disease such as hepatitis? A) Clotting factors B) Serum aminotransferases C) GGT D) Alkaline phosphatase

ANS: B Serum aminotransferases (previously called transaminases) are sensitive indicators of injury to the liver cells and are useful in detecting acute liver disease such as hepatitis.

The nursing instructor is talking about hepatitis with her clinical group. What would the instructor teach the students is the best method to prevent the transmission of the hepatitis E virus? A) Following proper hand-washing techniques B) Avoiding chemicals that are toxic to the liver C) Wearing a condom during sexual relations D) Isolating yourself from your family members

ANS: A Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. It is not necessary for the patient to isolate himself or herself from family members. Condom use is advised for patients with blood-borne hepatitis, such as hepatitis B, C, and D. Nonviral hepatitis is caused by the toxic effects of certain chemicals on the body and does not require transmission precautions.

The triage nurse in the emergency department is assessing a patient who presented with complaints of not feeling well. The patient has ascites and an enlarged liver. The patient reports a history of drinking a 12 pack of beer every evening for the past 15 years. The nurse is aware that the patient is at risk for which disease? A) Cirrhosis B) Renal failure C) Hepatitis D) Cardiovascular disease

ANS: A Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. There are three types of cirrhosis or scarring of the liver. This is most frequently due to chronic alcoholism. This patient's history does not put him or her at risk for renal failure, hepatitis, or cardiovascular disease.

A patient with a liver mass is undergoing a percutaneous liver biopsy. After the procedure the nurse assists the physician in positioning the patient. What position should they position the patient in? A) On the right side with a pillow under the costal margin B) Supine position C) On the left side with a pillow under the knees D) Trendelenberg position

ANS: A Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Instruct the patient to remain in this position, recumbent and immobile, for several hours. The patient will not be placed in the supine or the Trendelenberg position. Option C is incorrect.

A patient with a history of postnecrotic cirrhosis is being cared for on your unit. What is this type of cirrhosis often the result of? A) A previous bout of acute viral hepatitis B) Chronic alcoholism C) Bilary obstruction D) Cholangitis

ANS: A Postnecrotic cirrhosis involves broad bands of scar tissue and is the result of a previous bout of acute viral hepatitis. Alcoholic cirrhosis is most frequently due to chronic alcoholism. Biliary cirrhosis usually results from chronic biliary obstruction and infection (cholangitis).

A patient with liver cancer is undergoing radiation therapy. The patient asks the nurse if the radiation therapy is going to cure the cancer. What is the best answer the nurse could give? A) "The radiation therapy will hopefully prolong your life, but the major effect is palliative." B) "The radiation therapy is going to give you a second chance at life." C) "The radiation therapy will cure your cancer." D) "The radiation therapy will take away your pain and discomfort."

ANS: A Radiation therapy and chemotherapy have been used to treat cancer of the liver with varying degrees of success. Although these therapies may prolong survival and improve quality of life by reducing pain and discomfort, their major effect is palliative. The only complete answer is option

A patient has been admitted to the step-down unit with a diagnosis of liver malignancy. The critical care nurse caring for this patient is aware that an early manifestation of liver malignancy, in addition to pain, is what? A) A continuous dull ache in the right upper quadrant, epigastrium, or back B) Weight gain C) An increase in appetite D) Jaundice

ANS: A The early manifestations of malignancy of the liver include pain and a continuous dull ache in the right upper quadrant epigastrium or back. Weight loss, anorexia, and anemia may occur. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver.

The nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment the nurse notes that the patient has a flapping tremor of the hands. What will the nurse document this condition as in the patient's chart? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema

ANS: A The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

The nurse is caring for a patient with cancer of the liver. The patient has a percutaneous biliary drainage system. What assessments should the nurse record in the patient's chart? A) Amount and color of drainage B) Temperature of drainage C) Odor of drainage D) Consistency of drainage

ANS: A The percutaneous biliary system is open to external drainage. The bile is observed closely for the amount, color, and presence of blood and debris. The nurse would not record the temperature, odor, and consistency of the drainage.

How is hepatitis C transmitted? A) Unintentional needlesticks B) Fecal-oral route C) Contaminated food D) Airborne route

ANS: A Whereas blood transfusions and sexual contact once accounted for most cases of hepatitis C in the United States, other parenteral means, such as sharing contaminated needles by IV/injection drug users and unintentional needlesticks and other injuries in health care workers, now account for a significant number of cases. Hepatitis C is not spread by the fecal-oral or airborne route, and it is not spread by contaminated food.

A student asks the pathophysiology instructor what causes ascites. What would the instructor tell the student is involved in the physiologic process that causes ascites? (Mark all that apply.) A) Sodium and water retention B) A damaged liver C) Insufficient renal flow D) Increased lymphatic flow E) Decreased synthesis of immunoglobulin G

ANS: A, B, D Sodium and water retention, increased intravascular fluid volume, increased lymphatic flow, and decreased synthesis of albumin by the damaged liver all contribute to the movement of fluid from the vascular system into the peritoneal space. Insufficient renal blood flow and a decreased synthesis of immunoglobulin G do not play a part in the formation of ascites.

In end-stage liver disease, hypervolemia is always a problem. What nursing interventions would be most appropriate when caring for these patients? (Mark all that apply.) A) Administering diuretics B) Giving pain medications C) Implementing fluid restrictions D) Teaching nutrition E) Enhancing patient positioning

ANS: A, C, E Pulmonary compromise, which is always a potential complication of ESLD because of plasma volume excess, makes prevention of pulmonary complications an important role for the nurse. Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize pulmonary function.

A patient with bleeding esophageal varices is brought to the emergency department by the paramedics. An immediate endoscopy is performed. What nursing intervention is appropriate? A) Keep patient NPO until results of test are known. B) Keep patient NPO until gag reflex returns. C) Give anesthetic gargles until post-procedure soreness goes away. D) Give anesthetic lozenges 10 minutes before meals.

ANS: B After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient's physical condition and mental status permit. Appropriate nursing interventions do not include option A, as the result of the test is known immediately; anesthetic gargles and lozenges are contraindicated until the gag reflex returns.

A patient with liver cancer is at the clinic to talk with the physician. The physician tells the patient that it is to risky to do surgery on their hepatic tumor. The patient asks the nurse why surgery is so risky for them. The nurse explains that while surgical resection of the liver tumor is possible in some patients, the risks associated with this procedure increase when the patient has a history of what? A) Oral contraceptive use B) Cirrhosis C) Hypertension D) Prior abdominal surgery

ANS: B Although surgical resection of the liver tumor is possible in some patients, the underlying cirrhosis is so prevalent in cancer of the liver that it increases the risks associated with surgery. Oral contraceptive use is associated with benign liver tumors not malignant tumors. Prior abdominal surgery may have resulted in abdominal scar tissue formation, but poses minor if any risk to the patient. Hypertension can be controlled by use of anti-hypertensive drugs and again, poses a minor risk to the patient.

The nurse is caring for a patient with metastasis of her cancer to the liver. The patient is undergoing chemotherapy by TACE. What does this chemotherapy procedure cause? A) Necrosis of tumor cells B) Embolization of tumor vessels C) Necrosis of tumor vessels D) Embolization of tumor cells

ANS: B Embolization of tumor vessels with chemotherapy (a process known as transarterial chemoembolization [TACE]) produces anoxic necrosis with high concentrations of trapped chemotherapeutic agents. This procedure does not work on the cellular level of the tumor.

You are caring for a patient with a blocked bile duct from a tumor. What would you document about the patient's urine? A) Urine is dark amber and concentrated. B) Urine is orange and foamy. C) Urine is rust colored and concentrated. D) Urine is pale yellow and dilute.

ANS: B If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Therefore options A, C, and D are incorrect.

A 55-year-old female patient is undergoing radiofrequency thermal ablation of her primary liver tumor. What does this treatment entail? A) A tube is inserted into the tumor and ablation is done by superheated water. B) A needle electrode is inserted into the tumor and heated by radiofrequency. C) A tube is inserted into the tumor and chemotherapy is placed into the tumor. D) A needle electrode is inserted into the tumor and killed by laser.

ANS: B In radiofrequency thermal ablation, a needle electrode is inserted into the liver tumor under imaging guidance. Radiofrequency energy passes through to the noninsulated needle tip, causing heat and tumor cell death from coagulation necrosis. No tube is inserted into the tumor.

You are caring for a patient with advanced cirrhosis. You know that the most significant source of bleeding in a patient with cirrhosis is what? A) Portal hypertension B) Esophageal varices C) Hemolytic jaundice D) Ascites

ANS: B Once esophageal varices form, they are increase in size and eventually bleed; in cirrhosis, they are the most significant source of bleeding. Portal hypertension, hemolytic jaundice, and ascites are not sources of bleeding.

A nurse practitioner is teaching a health class in the local high school. The nurse practitioner informs the class about hepatitis B. What occupation does the nurse practitioner inform the class is at the greatest risk for contracting hepatitis B? A) Flight attendants B) Health care workers C) Fire fighters D) Educators

ANS: B People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. Health care workers who have had frequent contact with blood are screened for anti-HBs to determine whether immunity is already present from previous exposure. Flight attendants, fire fighters and educators are not at high risk for hepatitis B.

Toxic hepatitis has a poor prognosis if there is a prolonged period between the exposure to the toxin and the onset of symptoms. There are no effective antidotes. What is the clinical course of toxic hepatitis? 1. Fever rises. 2. Hematemisis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A) 12543 B) 12345 C) 23145 D) 31254

ANS: B Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure (discussed later) unless he or she receives a liver transplant.

A patient has come to the clinic with vague complaints that made the physician suspect liver disease. Laboratory work shows elevated GGT levels. What can elevated GGT levels indicate? A) Hemolytic jaundice B) Cirrohsis C) Liver cell dysfunction D) Viral hepatitis

ANS: C Increased GGT levels are associated with cholestasis but can also be due to alcoholic liver disease. Although the kidney has the highest level of the enzyme, the liver is considered the source of normal serum activity. The test determines liver cell dysfunction and is a sensitive indicator of cholestasis. An elevated GGT would not indicate hemolytic jaundice, cirrohsis, or viral hepatitis.

A patient with portal hypertension has been admitted to the floor you work on. What will you assess for related to portal hypertension? A) Bowel obstruction B) Vitamin A deficiency C) Ascites D) Hepatic encephalopathy

ANS: C Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Portal hypertension does not generally cause bowel obstruction. Vitamin A deficiency is not something the nurse assesses for. Hepatic encephalopathy is a complication of cirrohsis.

The nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep, has rigid extremities, and shows EEG abnormalities. Based upon these clinical findings, what is the patient's stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

ANS: C Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous; difficult to arouse; sleeps most of the time; exhibits marked confusion; incoherent in speech; asterixis; increased deep tendon reflexes; rigidity of extremities; marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. What is this patient at risk for? A) Chronic jaundice B) Pigment stones in portal circulation C) Brainstem damage D) Hepatomegaly

ANS: C Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for brainstem damage.

The nursing instructor is teaching the senior nursing students about liver disease. What would the instructor teach the students is the most common surgical procedure for liver cancer? A) Cryosurgery B) Liver transplantation C) A lobectomy D) Laser hyperthermia

ANS: C Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While liver transplantation and cryosurgery are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

A patient who has undergone liver transplantation is ready to be discharged home. The nurse is providing discharge teaching. Which topic will the nurse emphasize the most related to discharge teaching? A) The patient will obtain measurement of drainage from the T-tube. B) The patient will exercise three times a week. C) The patient will take immunosuppressive agents as required. D) The patient will monitor for signs of liver dysfunction.

ANS: C The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to assure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as they wouldn't go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress them like they would stress the immunosuppressive drug regimen.

A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has? A) Hemolytic jaundice B) Hepatic insufficiency C) Bleeding esophageal varices D) Portal hypertension

ANS: C The patient with bleeding esophageal varices may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. Signs and symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present. The scenario does not describe hemolytic jaundice, hepatic insufficiency, or portal hypertension.

A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A) Arterial line B) Central venous catheter C) Foley catheter D) Volume expanders

ANS: D Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Transfusion of blood components also may be required. An arterial catheter, a central venous catheter, and a Foley catheter will probably be ordered, but they won't maintain the patient's volume.

The nurse is reviewing the history of a patient newly admitted to the unit. This patient has been ordered vasopressin for bleeding esophageal varices. The nurse calls the physician to question the use of vasopressin when she reads that the patient has a history of what? A) Diabetes mellitus B) Chronic kidney disease C) Arthritis D) Coronary artery disease

ANS: D Coronary artery disease is a contraindication to the use of vasopressin, because coronary vasoconstriction is a side effect that may precipitate myocardial infarction. A history of diabetes, chronic kidney disease, or arthritis does not contraindicate the use of vasopressin.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals who ate at this restaurant and have never received the hepatitis A vaccine? A) The hepatitis A vaccine B) The hepatitis B vaccine C) The hepatitis A and B vaccines D) An immune globulin injection

ANS: D For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A.

The critical care nurse is caring for a patient with cirrhosis. What is an essential nursing function when caring for a patient with cirrhosis? A) Monitoring the patient's oral intake B) Monitoring the patient's support network C) Monitoring the patient for signs of hypervolemia D) Monitoring the patient's mental status

ANS: D Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. An extensive neurologic evaluation is key to identify progression through the four stages of encephalopathy. The nurse would monitor the oral intake and watch for signs of hypervolemia, but they are not as essential as the patient's mental status because of the encephalopathy that goes with cirrhosis. Monitoring the support network is not essential at this time.

The nurse is caring for a patient with liver failure. The nurse understands that patients in liver failure often require vitamin therapy. Which vitamin does the liver require for the synthesis of prothrombin? A) Vitamin B12 B) Vitamin A C) Vitamin D D) Vitamin K

ANS: D The liver requires vitamin K for the synthesis of prothrombin and some of the other clotting factors. Breakdown of fatty acids into ketone bodies occurs primarily when the availability of metabolism is limited, as during starvation or in uncontrolled diabetes. Vitamins stored in the liver include A, B12, D, and several of the B-complex vitamins.

A nurse is assessing a 77-year-old male admitted to the unit for suspected liver dysfunction. What assessment finding will the nurse expect to find? A) Liver function results change dramatically in the older adult. B) Metabolism of medications is delayed primarily by the liver. C) The liver is enlarged with hard edges. D) The liver is decreased in size and weight.

ANS: D The most common change in the liver is a decrease in size and weight. Results of liver function test results do not normally change in the elderly. Metabolism of medication is decreased by intestinal absorption, renal excretion, and altered body distribution of fat, as well as a decrease in liver function.

A young woman is being discharged after a liver transplant. The young woman asks the nurse when she will be able to try to become pregnant. What would be an appropriate response by the nurse? A) "You will never have a period after a liver transplant and you will never be able to get pregnant." B) "You can consider trying to get pregnant now. Let's start you on prenatal vitamins today." C) "You should see a fertility specialist to discuss this topic." D) "Pregnancy can be considered 1 year after transplantation, but it is considered a high-risk pregnancy and you will need to discuss this with your doctor."

ANS: D The nurse should immediately address the patient's question by stating that research indicates that pregnancy can be considered 1 year after transplantation. The patient should also be informed that successful pregnancy outcomes have been reported, but these pregnancies carry a risk for the mother and infant and are considered high-risk pregnancies. The female patient should be informed that she should use a reliable form of birth control as she will have her menses and be able to get pregnant and pregnancy should be avoided for at least 1 year.