Chapter 40 Liver (Hepatitis) - NCLEX
It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 1 Hepatitis A 2 Hepatitis B 3 Hepatitis C 4 Hepatitis D
1. Rationale: HAV is transmitted by the fecal-oral route via contaminated food or infected food handlers. HBV, HCV, and HDV are most commonly transmitted via infected blood or body fluids.
A client is admitted to the hospital with a diagnosis of acute viral hepatitis. Which sign/symptom would the nurse expect to observe based on this diagnosis? 1 Fatigue 2 Pale urine 3 Weight gain
1. Rationale:Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver
The client admitted to the hospital with a diagnosis of viral hepatitis is complaining of a loss of appetite. In order to provide adequate nutrition, which action would the nurse encourage the client to take? 1 Select foods high in fat. 2 Increase intake of fluids. 3 Eat less often, preferably only three large meals daily. 4 Eat a large supper when anorexia is most likely not as severe
2. Rationale:Although no special diet is required in the treatment of viral hepatitis, it is generally recommended that clients have a diet with low-fat content because fat may be poorly tolerated due to decreased bile production. Small frequent meals are preferable and may even prevent nausea. Often, the appetite is better in the morning, so it is easier to eat a healthy breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional fluids is also important
A health care worker who signed a waiver and never received the hepatitis B vaccine receives a needle stick from a client who has hepatitis B. Which treatments are indicated for the health care worker under this situation? Select all that apply. 1 Vitamin C orally 2 Ciprofloxacin orally 3 Hepatitis B immune globulin 4 Initiate hepatitis B vaccine series 5 Cleanse needlestick site with soap and water
3,4, 5 Rationale:The hepatitis B vaccine series is required for health care workers, but they may sign a waiver. A person exposed to the hepatitis B virus by needlestick should clean the puncture site with soap and water to decrease the risk of infection from the skin. The client should receive hepatitis B immune globulin, which contains the antibodies against the virus, and this will give passive immunity. The client should also begin the hepatitis B vaccine series to stimulate the client's own immune system to create antibodies against the hepatitis B virus. Vitamin C is not recommended. An antibiotic, such as ciprofloxacin, is not effective again viruses.
The nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the primary health care provider? 1 Delta antigen that is slightly decreased 2 White blood cell (WBC) count that is slightly elevated 3 Alanine aminotransferase (ALT) that is significantly elevated 4 Hepatitis B surface antigen (HBsAg) that is slightly decreased
3. Rationale:As tissues in the body are injured, enzymes present in the cells are released and can be monitored through blood tests. It is important to recognize which enzymes are found in which tissues. ALT is found predominantly in the liver, and an elevated level would indicate significant liver damage. The WBC count may be slightly elevated with the hepatitis. Antigens and delta antigen HBsAg, are agents that trigger cell damage; antigens do not result from the damage.
The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement? 1 "I should avoid alcohol and aspirin." 2 "I should eat a high-carbohydrate, low-fat diet." 3 "I should resume a full activity level within 1 week." 4 "I should take the prescribed amounts of vitamin K.
3. Rationale:The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K.
A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action? 1. Bathing the client with tepid water and mild soap only 2 Assessing and recording the client's weight twice daily 3 Monitoring red blood cell and white blood cell counts daily 4 Monitoring prothrombin and partial thromboplastin values
4. Rationale:When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients, bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Daily weight is often part of a nursing care plan but is more related to fluid balance than safety; monitoring weight twice daily would not be necessary. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue either.
The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure? 1 Washes and dries her hands before feeding 2 Requests that the window be closed before feeding 3 Holds the infant properly during feeding and burping 4 Tests the temperature of the formula before initiating feeding
1. Rationale:Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in prevention of the transmission of infection. Option 2 will not affect disease transmission. Options 3 and 4 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.
A client with a diagnosis of viral hepatitis has no appetite, and food makes the client nauseated. The nurse would conclude that which intervention is most appropriate? Your Answer: 1 Offer small, frequent meals. 2 Encourage foods low in calories. 3 Explain that high-fat diets are usually better tolerated. 4 Explain that the majority of calories needs to be consumed in the evening hours.
1. Rationale:If nausea persists, the client will need to be assessed for fluid and electrolyte imbalances. It is important to explain to the client that the majority of calories should be eaten in the morning hours because nausea most often occurs in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.
Which infection control method would the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? : 1 Hepatitis B vaccine 2 Proper personal hygiene 3 Use of immune globulin 4 Correct hand-washing technique
1. Rationale:Immunization is the most effective method of preventing hepatitis B infection. Other general measures include hand washing. Immune globulin may be used to prevent hepatitis A and is used for prophylaxis if the client is traveling to endemic areas. Personal hygiene, such as hand washing after a bowel movement and before eating, also helps prevent the transmission of hepatitis A.
A client with viral hepatitis states to the nurse, "I am so yellow." The nurse would best respond by taking which action? 1 Assist the client in expressing feelings 2 Restrict visitors until the jaundice subsides 3 Keep the client isolated from other clients and visitors. 4 Instruct the client that skin turning yellow is the consequence of alcoholism
1. Rationale:The client's feelings should be explored to discover how the client feels about the disease process and appearance so appropriate interventions can be planned. Restricting visitors, keeping the client isolated, and instructing the client that skin turning yellow is the consequence of alcoholism are inappropriate.
A sexually active 20-year-old client has been diagnosed with viral hepatitis. Which statement made by the client would indicate a need for further teaching? 1 I can never drink alcohol again." 2 I won't go back to work right away. 3 My close friends should get the vaccine. 4 A condom should be used for sexual intercourse."
1. Rationale:To prevent transmission of hepatitis, a condom is advised during sexual intercourse, as well as vaccination of the partner or close friends. Alcohol should be avoided for 1 year because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that the liver function has returned to normal. The client's activity is increased gradually.
The nurse is collecting data on a client admitted to the hospital with a diagnosis of hepatitis. The nurse would determine which data indicates the client may have liver damage? 1 Pruritus 2 Cool dry skin 3 Dark brown stools 4 Yellow, straw-colored urine
1. Rationale:Significant damage to liver cells renders them unable to metabolize bilirubin. When a red blood cell is broken down, hemoglobin is released. The heme portion is catabolized into unconjugated bilirubin. The liver then takes that unconjugated bilirubin and transforms it into conjugated bilirubin that passes into the hepatic ducts and eventually into the bowel, providing the normal brown color to stool. When bilirubin is not metabolized by the liver, it accumulates in the circulation and is minimally excreted by the skin, causing jaundice and pruritus. It is also eliminated unchanged by the kidneys, causing urine to become dark amber or brown.
The nurse is collecting admission data on the client with a diagnosis of hepatitis. Which finding would the nurse recognize to be a direct result of this client's condition? 1 Diarrhea 2 Drowsiness 3 Blurred vision 4 Urinary frequency
2. Rationale:Hepatitis impairs liver function. If the liver is unable to perform its metabolic and detoxification functions, waste products begin to accumulate in the body. Many of those wastes are protein by-products, especially ammonia, which are harmful to the central nervous system. An increased ammonia level is the primary cause of the neurological changes seen in liver disease, beginning with drowsiness. The remaining options are not directly related to hepatitis.
