Chapter 49: Assessment and Management of Patients With Hepatic Disorders NCLEX

B (Feedback: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.)

A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A) Administration of immune globulins B) A regimen of antiviral medications C) Rest and watchful waiting D) Administration of fresh-frozen plasma (FFP)

A, B (People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.)

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections

A (Feedback: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.)

A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A) Risk for Infection Related to Immunosuppressant Use B) Risk for Injury Related to Decreased Hemostasis C) Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis D) Risk for Contamination Related to Accumulation of Ammonia

D (Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. This is not the most common purpose of a nasogastric tube after surgery; instillations in a nasogastric tube after surgery are done when necessary to promote patency. This is contraindicated after abdominal surgery until peristalsis returns. This is not the most common purpose of a nasogastric tube after surgery; lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding.)

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? a) Lavage b) Gavage c) Instillation d) Decompression

C (Feedback: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.)

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A) IV administration of immune globulins B) Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C) Liver transplantation D) Lobectomy

B, C (Methods of treating portal hypertension aim to reduce venous pressure and fluid accumulation.)

A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension. What is the primary aim of portal hypertension treatment? Select all that apply. a) Reduce fluid output. b) Reduce fluid accumulation. c) Reduce venous pressure. d) Reduce blood coagulation.

B (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.)

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) Cure the cirrhosis. b) Reduce fluid accumulation and venous pressure. c) Treat the esophageal varices. d) Promote optimal neurologic function.

B (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.)

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) Blood pH of 7.25 b) Loss of 2.2 lb (1 kg) in 24 hours c) Serum sodium level of 135 mEq/L d) Serum potassium level of 3.5 mEq/L

A (Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.)

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) The digestion of dietary and blood proteins. b) Excess potassium loss subsequent to prolonged use of diuretics. c) Excessive diuresis and dehydration. d) Severe infections and high fevers.

C (Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation 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.)

Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A) Cryosurgery B) Liver transplantation C) Lobectomy D) Laser hyperthermia

A (Feedback: 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. Consequently, none of the other listed preventative measures is indicated.)

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A) Following proper hand-washing techniques B) Avoiding chemicals that are toxic to the liver C) Wearing a condom during sexual contact D) Limiting alcohol intake

A (The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth surface.)

In what location would the nurse palpate for the liver? a) Right upper quadrant b) Left upper quadrant c) Left lower quadrant d) Right lower quadrant

D (Lactulose (Cephulac) is administered to reduce serum ammonia levels. Cephulac does not influence calcium, bicarbonate, or alcohol levels.)

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? a) Calcium b) Alcohol c) Bicarbonate d) Ammonia

B (Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.)

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Bradycardia b) Hypotension c) Polyuria d) Warm moist skin

B (The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.)

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Fecal-oral c) Saliva d) Blood

D (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.)

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) Bumetanide (Bumex) b) Furosemide (Lasix) c) Acetazolamide (Diamox) d) Spironolactone (Aldactone)

D (If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.)

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? a) Urinary output related to increased sodium retention b) Peripheral vascular assessment related to immobility c) Skin assessment related to increase in bile salts d) Respiratory assessment related to increased thoracic pressure

B (Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.)

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a) Yellow-green b) Clay-colored or whitish c) Blood tinged d) Black and tarry

C (Feedback: Patients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.)

A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A) Increased potassium intake B) Fluid restriction to 2 L per day C) Reduction in sodium intake D) High-protein, low-fat diet

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. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.)

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A) Assessment of blood pressure and assessment for headaches and visual changes B) Assessments for signs and symptoms of venous thromboembolism C) Daily weights and abdominal girth measurement D) Blood glucose monitoring q4h

A (Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency leads to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Pyridoxine deficiency results in skin and mucous membrane lesions and neurologic changes. Vitamin C deficiency results in the hemorrhagic lesions of scurvy. Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses. Folic acid deficiency results in macrocytic anemia.)

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? a) Vitamin K deficiency b) Riboflavin deficiency c) Vitamin A deficiency d) Folic acid deficiency

C (The principal aim of therapy is to prevent further deterioration by abolishing underlying causes and preserving what liver function remains. The principal aim of therapy is to prevent further deterioration.)

An elderly homeless client with a lengthy history of alcohol addiction is visiting the health clinic where you work. He has worsening jaundice. After diagnostic testing is complete, the physician returns a diagnosis of cirrhosis. The nurse begins client education about this condition. What would the nurse emphasize as the principal goal of cirrhosis therapy? a) Restoring fat-soluble vitamin absorption b) Curing the illness c) Preserving liver function d) Increasing alcohol toleration

A (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.)

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

B (A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.)

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? a) Vasopressin (Pitressin) b) Transjugular intrahepatic portosystemic shunting (TIPS) c) Balloon tamponade d) Sclerotherapy

A (Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.)

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Maintaining the airway b) Relieving the patient's anxiety c) Controlling bleeding d) Maintaining fluid volume

B (Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.)

A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A) Finish all prescribed courses of antibiotics, regardless of symptom resolution. B) Adhere to dosing recommendations of OTC analgesics. C) Ensure that expired medications are disposed of safely. D) Ensure that pharmacists regularly review drug regimens for potential interactions.

A, C, D (Feedback: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.)

A patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

D (Feedback: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.)

A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A) Mobilization with assistance at least 4 times daily B) Administration of beta-adrenergic blockers as ordered C) Vitamin B12 injections as ordered D) Administration of diuretics as ordered

A (Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.)

The most common cause of esophageal varices includes which of the following? a) Portal hypertension b) Jaundice c) Ascites d) Asterixis

D (Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.)

The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? a) Spironolactone (Aldactone) b) Cholestyramine (Questran) c) Kanamycin (Kantrex) d) Lactulose (Cephulac)

B (Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment.)

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? a) Assessment of oral cavity for foul-smelling breath b) Daily weight and measurement of abdominal girth c) Palpation of abdomen for a fluid shift d) Auscultation of abdomen

D (Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.)

Which type of deficiency results in macrocytic anemia? a) Vitamin K b) Vitamin C c) Vitamin A d) Folic acid

D (In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. 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.)

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client? a) Spironolactone (Aldactone) b) Propranolol (Inderal) c) Lactulose (Cephulac) d) Vasopressin (Pitressin)

B (A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.)

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? a) Magnetic resonance imaging b) Liver biopsy c) Coagulation studies d) Radioisotope liver scan

A (Feedback: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.)

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A) Disposing of sharps appropriately and not recapping needles B) Performing meticulous hand hygiene at the appropriate moments in care C) Adhering to the recommended schedule of immunizations D) Wearing an N95 mask when providing care for patients on airborne precautions

D (For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune 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. Albumin confers no therapeutic benefit.)

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 to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A) The hepatitis A vaccine B) Albumin infusion C) The hepatitis A and B vaccines D) An immune globulin injection

C (Feedback: A fall would necessitate thorough medical assessment due to the patient's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.)

A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A) Remove the patient's commode and supply a bedpan. B) Complete an incident report and submit it to the unit supervisor. C) Have the patient assessed by the physician due to the risk of internal bleeding. D) Perform a focused abdominal assessment in order to rule out injury.

D (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.)

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

B (The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic dysfunction. 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.)

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 didn't take his morning dose of lactulose (Cephulac). b) The client's hepatic function is decreasing. c) The client is avoiding the nurse. d) The client is relaxed and not in pain.

B (Feedback: 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. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.)

A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A) Watery, blood-streaked diarrhea B) Orange and foamy urine C) Increased abdominal girth D) Decreased cognition

B (Feedback: 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. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.)

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A) Ensure that the patient's sodium intake does not exceed recommended levels. B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. C) Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D) Implement interventions aimed at ensuring a calm and therapeutic care environment.

C (Feedback: 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 hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C (Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.)

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures? a) Liver biopsy b) Dialysis c) Paracentesis d) Abdominal ultrasound

D (Feedback: Octreotide (Sandostatin)—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.)

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A) Infusion of intravenous heparin B) IV administration of albumin C) STAT administration of vitamin K by the intramuscular route D) IV administration of octreotide (Sandostatin)

C (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.)

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

A (Feedback: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.)

A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A) Implementation of infection-control measures B) Close monitoring of skin integrity and color C) Frequent assessment of the patient's psychosocial status D) Administration of antiretroviral medications

C (Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.)

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? a) Asterixis b) Cirrhosis c) Hepatic encephalopathy d) Portal hypertension

B (Feedback: The early manifestations of malignancy of the liver include pain—a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.)

A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A) Persistent fever and cognitive changes B) Abdominal pain and hepatomegaly C) Peripheral edema unresponsive to diuresis D) Spontaneous bleeding and jaundice

A (Feedback: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.)

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool

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 ensure 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 the patient 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 these topics over the immunosuppressive drug regimen.)

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? 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.

A, C, E (Feedback: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.)

A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply. A) Administering diuretics B) Administering calcium channel blockers C) Implementing fluid restrictions D) Implementing a 1500 kcal/day restriction E) Enhancing patient positioning

A (Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the patient's anxiety.)

A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient? a) "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." b) "It is easier to get a good tissue match with liver transplants than with other types of transplants." c) "The problem of rejection is not as common in liver transplants as in other organ transplants." d) "You would not be scheduled for a transplant if there was a concern about rejection."

C (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.)

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) Gynecomastia and testicular atrophy b) Ascites and orthopnea c) Purpura and petechiae d) Dyspnea and fatigue

A (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.)

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) Report the condition to the physician immediately. c) Provide the client with nonprescription laxatives. d) Ask the client about food intake.

A (Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.)

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Foul-smelling breath b) Palpation of abdomen for a fluid shift c) Measurement of abdominal girth d) Weight

D (Hemolytic jaundice is the result of an increased destruction of the red blood cells. Hepatocellular jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Obstructive jaundice resulting from extrahepatic obstruction may be caused by occlusion of the bile duct form a gall stone, inflammatory process, a tumor, or pressure from an enlarged organ. Nonobstructive jaundice occurs with hepatitis.)

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

C (Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.)

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis? a) Such clients can digest high-fat foods. b) Such clients are at risk for gallbladder contraction. c) Such clients cannot tolerate high-glucose concentration. d) Such clients are at risk for hepatic encephalopathy.