Chapter 49 Prep U

Which assessments are important in a client diagnosed with ascites?

Measurement of abdominal girth

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply.

diuretics albumin (Diuretics are given if circulating fluid is excessive. IV albumin may be given to pull fluid trapped in the peritoneum back into the circulation.)

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?

decompression

The nurse is educating a patient with cirrhosis about the importance of maintaining a low-sodium diet. What food item would be permitted on a low-sodium diet?

A pear

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?

Obstructive jaundice

A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse?

"Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated."

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?

"You must have the second one in 1 month and the third in 6 months."

A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk?

Abstain from drinking alcohol.

A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.

Acetaminophen Ketoconazole Valproic acid

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?

Ammonia

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?

Asterixis

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately?

Change in mental status

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?

Clay-colored or whitish

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Clay-colored stools

Which is an age-related change of the hepatobiliary system?

Decreased blood flow

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP)

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

Fecal-oral

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

Hepatic encephalopathy

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

Hepatitis C increases a person's risk for liver cancer.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply.

Jaundice Petechiae Ecchymoses

The nurse is administering medications to a client 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?

Lactulose

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

Octreotide (Sandostatin)

Which is the most common cause of esophageal varices?

Portal hypertension

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?

Purpura and petechiae

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction?

Radioisotope liver scan

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure.

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?

Scurvy

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?

The client's hepatic function is decreasing.

Which of the following liver function studies is used to show the size of abdominal organs and the presence of masses?

Ultrasonography

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?

Vasopressin (Pitressin)

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A

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?

Vitamin K deficiency

Which condition indicates an overdose of lactulose?

Watery diarrhea

When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply.

change in mental status signs of GI bleeding

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis.

A client with a lengthy history of alcohol addiction is being seen for jaundice. The appearance of jaundice would most likely indicate:

liver disorder.

What is the recommended dietary treatment for a client with chronic cholecystitis?

low-fat diet

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications?

metabolism of medications

A client who has worked for a company that produces paint and varnishing compounds for 24 years is visiting the clinic reporting chronic fatigue, dyspepsia, diarrhea, and a recently developing yellowing of the skin and sclera. The client reports clay-colored stools and frequent nosebleeds. Which type of cirrhosis is the likely cause of the client's symptoms?

postnecrotic

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:

subnormal serum glucose and elevated serum ammonia levels.

Which type of deficiency results in macrocytic anemia?

folic acid

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?

Liver biopsy

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction?

High-dose corticosteroids

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

Hypotension

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?

Loss of 2.2 lb (1 kg) in 24 hours

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

Maintaining the airway

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?

Respiratory assessment related to increased thoracic pressure