Exemplar 12.C - Liver Disease
A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing ascites, +3 pitting edema, and oliguria. Which nursing diagnosis should the nurse select as a priority for this client? A) Excess Fluid Volume B) Ineffective Peripheral Tissue Perfusion C) Deficient Fluid Volume D) Impaired Skin Integrity
A) Excess Fluid Volume The client experiencing ascites, edema, and oliguria should have a care plan for fluid volume excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.
The nurse is concerned that a client with potential hepatic failure is at risk for developing ascites. Which assessment finding supports the development of liver failure as manifested by ascites? A) Increased abdominal girth B) Gallbladder pain C) Yellow-tinged skin D) Bleeding and bruising easily
A) Increased abdominal girth Ascites is the accumulation of the fluid in the abdomen and is a result of liver failure. The client with ascites would have an increased abdominal girth. Jaundice is manifested as yellow-tinged skin and is the result of hepatic disorders. The client experiencing hepatic problems might have bleeding and bruising issues due to inadequate vitamin K. Obstructed biliary flow could be the cause of gallbladder pain.
Restricted blood flow through the liver results in which condition? A) Portal hypertension B) Cirrhosis C) Jaundice D) Biliary atresia
A) Portal hypertension Restricted blood flow through the liver results in portal hypertension, or increased pressure in the portal venous system. Jaundice results from impaired bilirubin conversion and excretion. Cirrhosis results when functional liver tissue is destroyed and replaced by fibrous scar tissue. Biliary atresia is a disorder of the bile ducts that causes backup of bile into the liver, resulting in tissue damage.
A client with liver disease presents to the hospital with severe ascites. What pathophysiologic changes does the nurse recognize as contributing to the development of ascites? Select all that apply. A) Presence of portal hypertension B) Presence of hyperalbuminemia C) Increased colloidal osmotic pressure D) Sodium and water retention E) Presence of hypoaldosteronism
A) Presence of portal hypertension D) Sodium and water retention Ascites is the accumulation of plasma-rich fluid in the abdominal cavity. Although portal hypertension is the primary cause of ascites, decreased serum proteins and increased aldosterone also contribute to the fluid accumulation. Hypoalbuminemia (low serum albumin) decreases the colloidal osmotic pressure of plasma. This pressure normally holds fluid in the intravascular compartment, but when the plasma colloidal osmotic pressure decreases, fluid escapes into extravascular compartments. Hyperaldosteronism (an increase in aldosterone) causes sodium and water retention, contributing to ascites and generalized edema.
The nurse is assessing a school-age child who complains of severe itching, bruising easily, restlessness, and involuntary jerking of the hands. When considering these manifestations collectively, which organ or system should the nurse anticipate needing to assess further? A) The liver B) The nervous system C) The gastrointestinal tract D) The urinary system
A) The liver Severe itching (pruritus) is common in children with liver cirrhosis. Bruising easily indicates a decreased clotting ability, which could be related to the inability of the liver to produce clotting factors. Restlessness and involuntary jerking of the hands (asterixis) are both signs of portal systemic encephalopathy. All of these symptoms relate to liver disease, particularly cirrhosis. Therefore, a history of infection or disease with liver involvement will be most important to obtain from this client. Infections or diseases with neural, gastrointestinal, or urinary involvement would not produce these symptoms.
What nursing intervention should be used to decrease pruritus in clients with liver disease? A) Vigorously scrub the skin with soap to prevent infection. B) Apply a lubricant on the skin to prevent dry skin. C) Use hot water rather than cool water when bathing the client. D) Administer an antihistamine as needed to reduce itching.
B) Apply a lubricant on the skin to prevent dry skin. Clients with pruritus require nursing interventions aimed at reducing itching and promoting skin integrity. Emollients or lubricants should be applied as needed to keep the skin moist. The skin should not be rubbed, and soap or preparations with alcohol should be avoided. Warm water should be used rather than hot water when bathing, because hot water increases pruritus. Antihistamines should be used cautiously because decreased liver function could alter drug responses.
A nurse is caring for a client with end-stage liver disease. Which alterations should the nurse anticipate with this client? Select all that apply. A) Elevated serum albumin levels due to increased protein synthesis B) Decreased clotting factor levels due to impaired clotting factor production C) Hyperglycemia due to disrupted glucose metabolism D) Increased serum vitamin K due to impaired clearance of fat-soluble vitamins E) Increased plasma oncotic pressure due to impaired protein metabolism
B) Decreased clotting factor levels due to impaired clotting factor production C) Hyperglycemia due to disrupted glucose metabolism Impaired function of liver cells has multiple effects. Impaired protein metabolism with decreased production of albumin and clotting factors occurs. Low albumin levels contribute to edema in peripheral tissues and ascites (accumulation of fluid in the abdomen), as plasma oncotic pressure is reduced, not increased. Impaired clotting-factor production increases the risk for bleeding. Disrupted glucose metabolism and storage may result in hyperglycemia. Also, serum vitamin K is decreased due to impaired absorption of fat-soluble vitamins.
The nurse is caring for a client who complains of jaundice and pruritus. The healthcare provider suspects that the client has liver disease. What modifiable risk factor for cirrhosis of the liver might the nurse see in the client's history? A) Smokes two packs of cigarettes per day B) Drinks a six-pack of beer each evening C) History of occupational exposure to hepatic toxins D) Family history of fatty liver disease
B) Drinks a six-pack of beer each evening Risk factors for the development of cirrhosis of the liver include excessive alcohol intake. Smoking is a risk factor for lung disease. A family history of fatty liver disease and past history of exposure to hepatic toxins may contribute to the risk of liver disease, but they are not modifiable risk factors.
The nurse is caring for a client recovering from a liver transplant necessitated by cirrhosis of the liver. Which postoperative outcome would be a priority for this client? A) Moist membranes of the mouth B) Normal serum bilirubin levels C) Ability to move the legs D) Normal pupil reaction
B) Normal serum bilirubin levels An indication for liver transplant is increasing bilirubin levels. Normal bilirubin levels after surgery would indicate that the transplanted liver is functioning correctly. Normal pupil reaction, leg movement, and moist mouth membranes are all normal findings for any postoperative client.
The nurse is identifying risk factors for liver disease among individuals who visit the community health center. Which does the nurse recognize as factors contributing to increased risk among certain ethnic groups? Select all that apply. A) Pollution B) Variations in alcohol metabolism C) Stress due to socioeconomic factors D) Consuming alcohol with food E) Climate
B) Variations in alcohol metabolism C) Stress due to socioeconomic factors Alcohol consumption is a leading cause of death for several ethnic populations. It is thought that contributing factors include variations in alcohol metabolism, socioeconomic factors that lead to stress, and consuming alcohol without food. Climate and pollution are not factors.
A new mother brings her 2-week-old infant in for a checkup because he looks jaundiced and his stools are white. The provider suspects the infant might have biliary atresia. What findings does the nurse anticipate upon assessment of the infant? A) Above average weight gain B) Increased urine output C) Abdominal distention D) Reduced rooting reflex
C) Abdominal distention Symptoms of biliary atresia usually appear 2 to 3 weeks after birth. They include jaundice, abdominal distention, white or clay-colored stools with putty-like consistency, tea-colored urine, and failure to thrive. This would result in below average weight gain rather than above average weight gain. Urine should be assessed for color, not volume. Biliary atresia may cause malnutrition due to poor absorption of nutrients, not a reduced rooting reflex.
When individuals engage in excessive alcohol consumption, which liver function is impacted, leading to subsequent liver damage? A) Metabolism B) Synthesis C) Detoxification D) Glycogen storage
C) Detoxification The liver is responsible for detoxifying alcohol and other substances. If an individual participates in high-risk behaviors such as excessive alcohol consumption, the detoxification function of the liver can be overwhelmed, resulting in damage to the liver. Metabolism of proteins, carbohydrates, and fats; synthesis of albumin and clotting factors; and glycogen storage are normal functions of the liver that help maintain health.
A client with liver cirrhosis begins to drain bright red blood through the nasogastric tube. Which should the nurse prepare to administer to this client? A) Vitamin K B) Ferrous sulfate C) Platelets D) Folic acid
C) Platelets Ferrous sulfate and folic acid are given as indicated to treat anemia. Vitamin K may be ordered to reduce the risk of bleeding. When bleeding is acute, packed RBCs, fresh frozen plasma, or platelets may be administered to restore blood components and promote hemostasis.
The nurse is providing education to the caregivers of a client with cirrhosis of the liver. The caregivers indicate that they've heard of portal hypertension, but they aren't sure which symptoms could indicate that their loved one is experiencing this condition. Which symptoms of portal hypertension should the nurse discuss with the caregivers? A) Muscle wasting B) Hypothermia C) Bleeding gums D) Hemorrhoids
D) Hemorrhoids Obstruction to portal blood flow causes a rise in portal venous pressure, resulting in splenomegaly, ascites, and engorgement of veins in the esophagus, rectum, and abdomen. Bleeding gums indicate insufficient vitamin K production in the liver. Muscle wasting is commonly associated with the poor nutritional intake seen in clients with cirrhosis. Hypothermia is an unrelated finding.