Presentation Questions

Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) A. Assessing the client's neurologic status every 2 hours B. Monitoring the client's hemoglobin and hematocrit levels C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily E. Preparing to insert an esophageal tamponade tube F. Making sure the client's fingernails are short

A. Assessing the client's neurologic status every 2 hours C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to convert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.

What are some complications for DM Type 1? A. Hyperglycemia ---Diabetic ketoacidosis B. Hypoglycemia C. Retinopathy D. Neuropathy E. Nephropathy

A. Hyperglycemia ---Diabetic ketoacidosis

A cirrhosis patient appears disoriented with flapping hands. What lab confirms these findings? A. Increased ammonia B. Decreased potassium C. Increased magnesium D. Decreased creatinine

A. Increased ammonia

Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily B. Evidence of watery diarrhea C. Daily deterioration in the client's handwriting D. Appearance of frothy, foul-smelling stools

A. Passage of two or three soft stools daily Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.

Alcohol abuse, drug abuse & tobacco smoking can increase the risk of cirrhosis. A. True B. False

A. True

Meat products can increase ammonia levels in the body. A. True B. False

A. True

When caring for a pt 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. teach pt to avoid straining at stool, vigorous blowing of nose, and coughing C. advise pt to use soft-bristle toothbrush and avoid ingestion of irritating food. D. apply gentle pressure for the shortest possible time period after performing venipuncture E. instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

A. use smallest gauge needle possible when giving injections or drawing blood. B. teach pt to avoid straining at stool, vigorous blowing of nose, and coughing C. advise pt to use soft-bristle toothbrush and avoid ingestion of irritating food. E. instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. - small gauge minimize risk of bleeding into tissues. - avoiding strain reduces hemorrhage - soft bristle reduce injury to highly vascular mucous membranes - apply gentle but prolonged pressure to venipuncture - aspirin and NSAIDs should not be used in pt with liver disease b/c they interfere w/ platelet aggregation, increasing bleeding risk

The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this pt? A.Low-protein B.High-protein C.Moderate-fat D.High-carb

A.Low-protein Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia.

For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? A. Allowing complete independence of mobility B. Applying pressure to injection sites C. Administering antibiotics as prescribed D. Increasing nutritional intake

B. Applying pressure to injection sites The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client's potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.

What medication is used to eliminate ammonia from the body? A.Potassium B. Lactulose C. Activated Charcoal D. IV Fluids

B. Lactulose

How is ammonia excreted from the body when taking lactulose? A. Urine B. Stool C. Sweat D. Blood

B. Stool

The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's best response is based on the knowledge that A. a lack of clotting factors promotes the collection of blood in the abdominal cavity B. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space. C. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel D. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid

B. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space. Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension, protein shifts from the blood into the lymph. When the lymph system is unable to carry excess, it leaks thru the liver into the peritoneal cavity. osmotic pressure of the proteins pulls additional fluid into cavity. Second mechanism of ascites if hypoalbuminemia from the liver unable to synthesize albumin, resulting in decreased colloidal oncotic pressure.

A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise B. Stomatitis C. Hand tremors D. Weight loss

C. Hand tremors Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.

The nurse is correct in understanding that which of the following statements about the peak time of Lantus insulin is correct? A. There is no peak time, insulin is delivered at a steady level. B. Peak time is 30-60 minutes C. Peak time is 24 hours D. It peaks when the patient eats their next meal.

Correct answer: A Rationale: Lantus is a long-acting insulin with no peak time, it is delivered at a steady level throughout 20-24 hours (duration of action).

Which statement by the parent of a 15-year old female diagnosed with Type 1 Diabetes requires further teaching? A. I understand that my daughter will outgrow diabetes when she becomes an adult. B. Some early signs of hypoglycemia I may recognize are: shakiness, sweating, difficulty paying attention, and hunger. C. I understand that there is no cure for type 1 diabetes. D. I understand that the pancreas is unable to produce enough insulin, so my daughter requires insulin.

Correct answer: A Rationale: The mother requires further education because type 1 diabetes is chronic and lifelong, requiring lifelong treatment. There is no cure for type 1 diabetes, but it can be managed.

Which of the following are classic signs / symptoms of hyperglycemia? Select all that apply: A. Polyuria B. Hypernatremia C. Polydypsia D. Polyphagia

Correct answer: A,C,D Rationale: Polyuria, polydipsia, and polyphagia are the 3 classic signs / symptoms of hyperglycemia. Polyuria reabsorbs sugar and returns it to the bloodstream, due to abnormally high levels of sugar, not all of it can be reabsorbed back into the bloodstream which causes it to be excreted through the urine, drawing more water. Polyphagia is caused by the glucose being unable to enter the cells due to a lack of insulin or insulin resistance, which leads to a lack of energy and increased hunger. Polydypsia is a result from polyuria (excessive urination) causing dehydration.

The nurse shows understanding of Erickson's developmental stages based on which of the following for a 15-year old female who is diagnosed with Type 1 Diabetes and is focused on losing weight for prom. A. She is in the intimacy vs. Isolation phase. B. She is in the Identity vs. Role confusion phase. C. She is in the Industry vs. inferiority phase. D. None of the above.

Correct answer: B Rationale: A 15-year female without developmental delay falls into the Identity vs. Role Confusion phase where social relationships and developing a sense of identity & self are the focus.

The nurse observes a type 1 diabetic child with the following symptoms: diaphoresis, irritability, shakiness and the child is pale. What is the best nursing action? A. Give the child a cup of whole fat milk B. Give the child a cup of orange juice C. Immediately administer glucagon D. Administer epinephrine

Correct answer: B Rationale: Orange juice is the most appropriate choice for a child who is conscious and showing signs of hypoglycemia

A patient with Type 1 Diabetes becomes hyperglycemic and has a blood glucose level of 241 mg/dL, the nurse is aware that which of the following actions is correct when administering insulin? A. Insulin must be given intramuscularly B. Another nurse must verify the dosage prior to administration. C. Must shake insulin prior to drawing it. D. Must call Physician due to abnormally high blood glucose level.

Correct answer: B Rationale: Regardless of the route of administration, it is critical that another nurse verifies the dosage of insulin prior to administration. Giving too much insulin can cause hypoglycemia and cause harm to the patient.

The nurse knows that which of the following about Type 1 Diabetes is TRUE? A. It is a temporary condition that can be resolved with a healthy diet and exercise. B. It is a chronic condition where the pancreas produces little or no insulin. C. Type 1 Diabetes can be controlled without insulin. D. Type 1 Diabetes accounts for over 80% of all diagnosed Diabetics.

Correct answer: B Type 1 Diabetes is a chronic condition where the pancreas produces little or no insulin and requires insulin.

6.The nurse is correct in understanding that which of the following can increase insulin needs? Select all that apply: A. Exercise B. Stress C. Infection D. Illness E. Puberty

Correct answer: B,C,D,E Rationale: Stress, infection, growth spurts, puberty, and illness can all increase insulin needs. During these events growth hormone and / or cortisol levels rise in the body which causes tissues to be less sensitive to insulin.

The nurse has just given a patient a glass of orange juice due to a blood glucose reading of 47 mg/dL. What is the nurses next priority intervention? A. Call physician immediately. B. Administer a second glass of orange juice. C. Re-assess blood glucose level in 15 minutes. D. Administer 3 units of insulin.

Correct answer: C Rationale: The nurse must first re-assess blood glucose levels 15 minutes after to see if the orange juice increased blood glucose levels.

The nurse is aware that which of the following is an emergency medication for hypoglycemia? A. Epinephrine B. Narcan C. Sodium gluconate D. Glucagon

Correct answer: D Rationale: Glucagon releases glucose back into the bloodstream in severe hypoglycemia when the patient is unconscious or unable to help themselves. Glucagon is an emergency medication to treat hypoglycemia.

Which rationale supports explaining the placement of an esophageal tamponade tube in a client who is hemorrhaging? A. Allowing the client to help insert the tube B. Beginning teaching for home care C. Maintaining the client's level of anxiety and alertness D. Obtaining cooperation and reducing fear

D. Obtaining cooperation and reducing fear An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client's cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client's anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.

Which is a sign that lactulose is working effectively to remove ammonia from the body? A. Patient has shallow breathing B. Decreased insulin in the blood C. Presence of asterixis D. Patient is conscious & alert

D. Patient is conscious & alert

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this pt by assessing what? A. relief of constipation B. relief of ab pain C. decreased liver enzymes D. decreased ammonia levels

D. decreased ammonia levels hepatic encephalopathy is associated with elevated ammonia levels. Lactulose traps ammonia in the intestinal tract. It's laxative effect then expels ammonia from the colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.

When planning care for a pt with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. impaired skin integrity related to edema, ascites, and pruritis B. imbalanced nutrition: less than body requirements related to anorexia C. excess fluid volume related to portal hypertension and hyperaldosteronism D. ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D. ineffective breathing pattern related to pressure on diaphragm and reduced lung volume airway and breathing are always highest priority.