Ch 43: Assessment and Management of Patients with Hepatic Disorders

d) Parenchymal cells Pg. 1370 The parenchymal cells perform most of the liver's metabolic functions.

2. Most of the liver's metabolic functions are performed by: a) Kupffer cells b) Canaliculi cells c) Islets of Langerhans d) Parenchymal cells

a) Vitamin K Pg. 1384 Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

34. A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a) Vitamin K b) Oral bile acids c) Potassium d) Vitamin B

d) Watery diarrhea Pg. 1382 The client receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

9. Which condition indicates an overdose of lactulose? a) Hypoactive bowel sounds b) Fecal impaction c) Constipation d) Watery diarrhea

b) N-acetylcysteine Pg. 1392 Acute hepatic failure or acute liver failure (ALF) is the clinical syndrome of sudden and severely impaired liver function in a person who was previously healthy. Supporting the client in the ICU and assessing the indications for and feasibility of liver transplantation are hallmarks of management. The use of antidotes for certain conditions may be indicated, such as N-acetylcysteine for acetaminophen toxicity. Penicillin is used for mushroom poisoning. Prostaglandins are used to enhance hepatic blood flow. Plasma exchange is used to correct coagulopathy, reduce serum ammonia levels, and stabilize the client awaiting liver transplantation.

1. A critically ill client is diagnosed with acute liver failure caused by an overdose of acetaminophen. Which treatment will the nurse anticipate being prescribed for the client? a) Penicillin b) N-acetylcysteine c) Plasma exchange d) Prostaglandins

d) Hemolytic Pg. 1371 Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in clients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive and hepatocellular jaundice are the result of liver disease. Nonobstructive jaundice occurs with hepatitis.

10. The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction? a) Hepatocellular b) Nonobstructive c) Obstructive d) Hemolytic

a) Arrange for a low air loss bed Pg. 1397 Initiating the use of an alternating-pressure mattress or low air loss bed decreases the risk for skin breakdown due to prolonged pressure on bony prominences. The other answers do not apply.

11. The nurse completing a plan of care for a client with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which nursing intervention is appropriate for this problem? a) Arrange for a low air loss bed b) Reposition the client every 4 hours c) Perform passive range-of-motion exercises four times a day d) Restrict dietary protein intake

b) Obstructive jaundice Pg. 1371-1372 Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.

12. A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has? a) Cirrhosis of the liver b) Obstructive jaundice c) Hemolytic jaundice d) Hepatocellular jaundice

c) Hemolytic Pg. 1371 Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive and hepatocellular jaundice are results of liver disease. Nonobstructive jaundice occurs with hepatitis.

13. Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a) Obstructive b) Hepatocellular c) Hemolytic d) Nonobstructive

d) Subnormal serum glucose and elevated serum ammonia levels Pg. 1400-1402 In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

14. A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) Elevated liver enzymes and low serum protein level b) Elevated blood urea nitrogen and creatinine levels and hyperglycemia c) Subnormal clotting factors and platelet count d) Subnormal serum glucose and elevated serum ammonia levels

a) Loss of 2.2 lb (1 kg) in 24 hours Pg. 1373 Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

15. A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Loss of 2.2 lb (1 kg) in 24 hours b) Serum potassium level of 3.5 mEq/L c) Serum sodium level of 135 mEq/L d) Blood pH of 7.25

b) Spironolactone (Aldactone) Pg. 1395 Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

16. The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? a) Furosemide (Lasix) b) Spironolactone (Aldactone) c) Bumetanide (Bumex) d) Acetazolamide (Diamox)

b) Anorexia, nausea, and vomiting Pg. 1386 Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

17. A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a) Severe abdominal pain radiating to the shoulder b) Anorexia, nausea, and vomiting c) Abdominal ascites d) Eructation and constipation

d) The client's hepatic function is decreasing Pg. 1381 The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

18. A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client is avoiding the nurse b) The client is relaxed and not in pain c) The client didn't take his morning dose of lactulose (Cephulac) d) The client's hepatic function is decreasing

d) The digestion of dietary and blood proteins Pg. 1381 The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

19. Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: a) Severe infections and high fevers b) Excessive diuresis and dehydration c) Excess potassium loss subsequent to prolonged use of diuretics d) The digestion of dietary and blood proteins

a) Scurvy Pg. 1384 Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

20. Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency? a) Scurvy b) Hypoprothrombinemia c) Beriberi d) Night blindness

d) "You must have the second one in 1 month and the third in 6 months" Pg. 1389-1390 Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

21. A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? a) "You must have the second one in 2 weeks and the third in 1 month" b) "You must have the second one in 1 year and the third the following year" c) "You must have the second one in 6 months and the third in 1 year" d) "You must have the second one in 1 month and the third in 6 months"

a) Liver resection Pg. 1406 Surgical resection is the treatment of choice when liver cancer is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. The use of external-beam radiation for the treatment of liver tumors has been limited by the radiosensitivity of normal hepatocytes and the risk of destruction of normal liver parenchyma. Studies of clients with advanced cases of liver cancer have shown that the use of systemic chemotherapeutic agents leads to poor outcomes. Laser hyperthermia has been used to treat hepatic metastases.

22. A client with right upper quadrant pain and weight loss is diagnosed with liver cancer. For which treatment will the nurse prepare the client when it is determined that the disease is confined to one lobe of the liver? a) Liver resection b) Radiation c) Chemotherapy d) Laser hyperthermia

c) On the right side Pg. 1369-1370 In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

23. A client has undergone a liver biopsy. Which postprocedure position is appropriate? a) On the left side b) High fowler c) On the right side d) Trendelenburg

c) Spironolactone Pg. 1373 The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion). Acetazolamide and ammonium chloride are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.

24. A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? a) Furosemide b) Acetazolamide c) Spironolactone d) Ammonium chloride

a) "How did this happen? I've been faithful my entire marriage" Pg. 1385 The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered.

25. A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? a) "How did this happen? I've been faithful my entire marriage" b) "I'll wash my hands often" c) "I'll take all my medications as ordered" d) "I'll be very careful when preparing food for my family"

c) Octreotide Pg. 1377 In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Octreotide (Sandostatin) causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage. 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 clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

26. A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client? a) Propranolol b) Spironolactone c) Octreotide d) Lactulose

d) Vaccine Pg. 1388-1389 The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

27. Which of the following is the most effective strategy to prevent hepatitis B infection? a) Covering open sores b) Avoid sharing toothbrushes c) Barrier protection during intercourse d) Vaccine

d) Reduce fluid accumulation and venous pressure Pg. 1377 Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

28. A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a) Treat the esophageal varices b) Cure the cirrhosis c) Promote optimal neurologic function d) Reduce fluid accumulation and venous pressure

d) Clay-colored stools Pg. 1371-1372 Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

29. A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? a) Elevated urobilinogen in the urine b) Straw-colored urine c) Reduced hematocrit d) Clay-colored stools

c) Abdominal paracentesis Pg. 1374 Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain. Fluid is removed from the lung via a thoracentesis. Fluid cannot be removed with an abdominal CT scan, but it can assist with placement of the needle. Fluid cannot be removed via an upper endoscopy.

3. The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed? a) Thoracentesis b) Abdominal CT scan c) Abdominal paracentesis d) Upper endoscopy

d) Vasopressin Pg. 1377 Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

30. Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? a) Spironolactone b) Nitroglycerin c) Cimetidine d) Vasopressin

d) Purpura and petechiae Pg. 1396-1398 A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

31. 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? a) Dyspnea and fatigue b) Gynecomastia and testicular atrophy c) Ascites and orthopnea d) Purpura and petechiae

a) Asterixis Pg. 1368 Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances.

32. Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction? a) Asterixis b) Paracentesis c) Ascites d) Dialysis

c) Decreased blood flow Pg. 1367 Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

33. Which is an age-related change of the hepatobiliary system? a) Enlarged liver b) Decreased prevalence of gallstones c) Decreased blood flow d) Increased drug clearance capability

c) Level of consciousness (LOC) Pg. 1382 In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

4. A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: a) Abdominal girth b) Stool frequency c) Level of consciousness (LOC) d) Urine output

a) Measure abdominal girth according to a set routine Pg. 1404 If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

5. When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a) Measure abdominal girth according to a set routine b) Ask the client about food intake c) Report the condition to the physician immediately d) Provide the client with nonprescription laxatives

c) A liver biopsy Pg. 1395 A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

6. A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a) Platelet count b) A CT scan c) A liver biopsy d) A prothrombin time

a) Hepatitis C increases a person's risk for liver cancer Pg. 1385 Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

7. A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Hepatitis C increases a person's risk for liver cancer b) Infection with hepatitis G is similar to hepatitis A c) Hepatitis A is frequently spread by sexual contact d) Hepatitis B is transmitted primarily by the oral-fecal route

c) "How often do you drink alcohol?" Pg. 1393 The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.

8. 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? a) "Does your work expose you to chemicals?" b) "Have you had an infection recently?" c) "How often do you drink alcohol?" d) "What type of over-the-counter pain reliever do you use?"