Chapter 61

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?

Bilirubin

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?

Ascites

A client who has liver disease has undergone a percutaneous needle biopsy. Which is the priority nursing assessment for the client after this procedure?

Assessing for bleeding

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record?

Asterixis

A client who has liver disease with ascites asks about any necessary dietary changes. What instruction does the nurse include when teaching this client?

Avoid using table salt

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication?

Bleeding

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN?

Client with end-stage cirrhosis who needs teaching about a low-sodium diet

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first?

Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse

The community health nurse is exploring the cause of an outbreak of hepatitis A. Which individual does the nurse suspect may be the source?

Clients who were infected after eating at the same restaurant

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered?

Colon cancer with metastasis to the liver

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend?

Consuming increased carbs and moderate protein

When caring for a client with Laennec's cirrhosis and portal hypertension, which point is essential for the nurse to emphasize to the client and family?

Do not consume any alcohol

The nurse is teaching a spouse and client with hepatitis C about preventing the spread of infection. Which instruction does the nurse include in the teaching plan?

Do not share toothbrushes

Which activity by the nurse will best relieve symptoms associated with ascites?

Elevate head of the bed

A client who contracted hepatitis C several years ago via intravenous drug use appears angry and withdrawn and refuses to participate in self-care activities and exercise. Which initial action by the nurse is correct?

Encourage the client to discuss feelings of guild or remorse

The nurse is caring for a client with cirrhosis and profound ascites. Which assessment finding causes the nurse to notify the provider?

Inaudible breath sounds

Which statement about hepatitis A is accurate?

It is transmitted by the fecal-oral route

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation?

Keeping the T-tube in a dependent position

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?

Lean meats

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection?

Members of the household must not share toothbrushes

When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B?

Men who prefer sex with ment

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease?

My liver is scarred, but the cells can regenerate themselves and repair the damage

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these?

NSAIDs

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?

Not eating salt is an acquired taste, which you can become used to.

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?

Obtain pulse and BP

Which individual has the greatest risk for developing hepatitis A?

Person who consumes raw oysters

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?

Petechiae

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)?

Placing client in semi-fowlers position

The nurse administers lactulose (Cephulac) to a client with cirrhosis for which purpose?

Promotes GI excretion of ammonia

A client who has early signs of hepatic encephalopathy may be asked to make which changes in the diet?

Reduce protein

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Cephulac)?

Requests a beside commode for the client

What is a feature of hepatic abscess?

Right upper abdominal pain is a common manifestation

Which precaution is most appropriate for the nurse to implement with a client with hepatitis A?

Standard Precautions

A client with cirrhosis is preparing for discharge home. What instruction does the nurse include when teaching this client about dietary supplements?

Use only supplements prescribed by the provider

A client diagnosed with hepatitis A asks the nurse how this disease may have been contracted. Which answer by the nurse is correct?

You may have consumed foods contaminated with the virus

The nurse is counseling an asymptomatic client who is worried about possible hepatitis C exposure several years ago. What does the nurse tell this client about the risk of this disease?

You may have serious long-term damage even without symptoms