HESI: Hepatitis Case Study and Rationale

25. After three months of treatment, client and her mother visit the health clinic. Client is recovering well, she began a new semester, and she has a full time job to help cover her medical expenses. She and her mother moved into a smaller single bedroom apartment closer to her school. She has adhered to her prescribed regimen and has been getting plenty of rest. Client reports that her energy level and appetite are back to normal. Client is worried about her mom. She states her mom is homesick and does not like being alone when client is gone. She does not speak English well, and has only met a few people since she has been living with client. Coupled with not feeling well herself has caused a change in the mother's behavior. The nurse notes that the mother is quiet and only interacts with the nurse minimally. The nurse notes that the mother's energy level is still low and she lacks enthusiasm to participate in any activities. When the nurse asks how she is doing, the mother states, "This is a terrible feeling. I don't know if I want to go on like this." What is the best initial response by the nurse?

"You seem very discouraged right now." (This response displays active listening and acknowledges the mother's statement. It also invites further disclosure.)

9. Which problem areas are important to include in client's plan of care? (Select all that apply. One, some, or all options may be correct.)

-Adequate nutritional intake. -Pruritus. -Fatigue A client with hepatitis often experiences fatigue and malaise, resulting in activity intolerance. Pruritus from increased bile salt excretion through the skin can cause itching. If the client responds by scratching, skin breakdown can happen. Since symptoms of acute hepatitis C include decreased appetite and nausea and vomiting, nutrition can be affected. Nurses need to be aware and monitor for this.

11. Client states she has no real appetite and that food doesn't taste right. Which interventions should the nurse implement to help with her nutritional status? (Select all that apply. One, some, or all options may be correct.)

-Develop a list of between meal snacks for the client to choose from. -Encourage increased fluid intake, especially juices. (This intervention individualizes care and takes into consideration both dietary requirements and client preferences. An adequate intake of fluids around 2500 to 3000 mL/day including nutritional juices is important.)

5. The HCP prescribes sodium chloride 0.9% for hydration. The nurse sets up a 1000 mL bag of sodium chloride 0.9% to administer the prescribed dose of 100 mL/hr per IV. The IV tubing has a drop factor (gtt) of 12 drops (gtts)/mL/min. The IV should infuse at how many drops per minute? (Enter the numerical value only. If rounding is required, round to the whole number.)

20 The formula for IV is volume to be infused over the time in minutes multiplied by the drop factor. 100 mL/60 x 12 = 20 drops/minute

2. After a more thorough history and assessment, the healthcare provider (HCP) notes that client reports being a little bit sore under her right rib cage. Based on this information, the nurse anticipates which priority lab test?

ALT, AST. (An enlarged liver can produce soreness/tenderness under the right rib cage area.)

15. Client's acute symptoms are resolved, and she is preparing to be discharged home. Which discharge instruction should the nurse include in the teaching plan?

Do not share personal hygiene items. (Sharing personal hygiene items (i.e., nail clippers, razors, etc.) may increase the risk for virus transmission.)

21. Biopsy results and screening indicate that client's mother has chronic hepatitis B. The only significant history her mother recalls is receiving a blood transfusion with her past 2 surgeries back in the early 1970s. She is started on alpha-interferon, 10 million units subcutaneously (SQ) 3 times a week for 16 weeks and lamivudine 150 mg by mouth (PO) daily. Which adverse effects of interferon therapy should the nurse include in the teaching plan?

Flu-like aches and pains. (Because interferon is a biologic response modifier, it promotes improved immune system functioning and may initiate an inflammatory response, causing flu-like symptoms.)

12. What infection prevention interventions are required by the hospital staff who come in direct contact with client?

Gown and gloves are to be used when handling urine or feces. (Hepatitis A is transmitted by the fecal-oral route; therefore, precautions should be used when handling contaminated specimens.)

1. What additional information would be helpful to the nurse as related to client's presentation?

Have the client to explain her mission work. (The social conditions in foreign countries can help to focus other areas of assessment.)

3. Client's lab results reveal an elevated liver enzymes. The healthcare provider (HCP) sends blood for hepatitis screening. The results indicate that client has hepatitis. Based on her history, which type of hepatitis does the nurse suspect?

Hepatitis A. (Hepatitis A is caused by contaminate fecal contamination of food or drinking water, poor sanitary conditions, improper handling of food, poor hygiene and crowded conditions. Spending time at a missionary site and being from a low socioeconomic area places client at high risk.)

22. The nurse evaluates client's mother's understanding of chronic hepatitis. Which statement indicates that more teaching is needed?

I can drink wine and mixed cocktails, but I have to limit to once a week. (All sources of alcohol should be avoided. Alcohol is very hepatotoxic and will destroy more liver tissue.)

17. What recommendations for prophylaxis should the nurse provide for client's roommates?

Immune globulin. (Immune globulins is recommended for household members of people with hepatitis A.)

13. Client's mother is going to stay with her in the hospital until she is discharged. What teaching should the nurse provide related to use of the in room bathroom?

It is important that you wash your hands for at least 15 seconds after using the bathroom. (Hepatitis A is spread by the fecal-oral route. Transmission is prevented by proper handwashing.)

6. Client is admitted to the hospital for further workup and teaching. While performing a physical assessment, the nurse notes that her skin has a slight yellow cast.

Jaundice. (Jaundice occurs when excess bilirubin diffuses through the skin. Normal total serum bilirubin is 0.1 to 1.2 mg/dL (1.71 - 20.52 µmol/L in adults. Jaundice occurs when the total serum bilirubin exceeds 2.5 mg/dL (42.76 µmol/L). Jaundice is also often noted in the sclerae of the eyes.)

10. Which priority nursing intervention should the nurse implement for pruritus?

Massage skin with an emollient several times a day. (If pruritus is a problem, special skin care and protection are needed. Eliminate bath soaps and apply emollient lotions.)

14. Some of client's family members have arrived from Mexico to be with her during her illness. She asks if she can use an over the counter (OTC) herbal supplement to help her liver heal.

Milk thistle. (This supplement is used for antitoxin properties and to protect against liver disease.)

20. In which position should the client be maintained immediately after the biopsy?

Positioned on the right side with a pillow under the costal margin. (Immediately after the biopsy, the client should remain on the right side for at least 2 hours. This position applies pressure to the liver capsule at the puncture site.)

19. Prior to the liver biopsy, it is most important for the nurse to be aware of which lab test result?

Prothrombin time. (Since the biopsy is an invasive procedure and altered liver function can cause a prolonged prothrombin time, it is most important for the nurse to be aware of any potential for bleeding and to inform the HCP of an abnormal prothrombin time.)

18. During the time her mother is with her, client's mother becomes ill and is seen by client's HCP. During the workup, her mother is evaluated and her liver function tests show increased levels. The HCP schedules her for a liver biopsy on an outpatient basis. An increase in which diagnostic lab test reflect that the liver is not functioning adequately?

Serum bilirubin. (Serum bilirubin generally increases when the liver is damaged, along with other serum liver enzymes such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), and serum alkaline phosphatase.)

7. Since client has jaundice, the nurse carefully observes the urine and stool. Which observation about the stool is consistent with the presence of jaundice?

Stool is clay-colored. (Stool will be light or clay-colored if conjugated bilirubin is not able to leave the liver.)

4. When client receives the diagnosis, she is upset and asks, "I am scared, does this mean I am dying?" What is the best response by the nurse?

Tell the client that she must feel scared and afraid and allow her to express her feelings. (This reflects the client's feelings and encourages more exploration of concerns.)

24. Which information communicated by client needs intervention from the nurse?

The client states that her mother only takes acetaminophen when she has a head ache or body aches. (Acetaminophen can cause hepatotoxicity in large doses. A client with hepatitis should avoid substances that may cause liver damage, such as hepatotoxic medications and alcohol.)

23. Client and her mother return in six weeks for a follow up appointment. The mother is diagnosed with a urinary tract infection. The nurse should question which medication that is prescribed for the mother?

Trimethoprim-sulfamethoxazole. (This is a sulfa based drug that potentially cause hepatotoxicity and jaundice.)

8. Which observation about the urine is consistent with the presence of jaundice?

Urine is tea-colored. (As excess bilirubin builds in the bloodstream, some is excreted in the urine, which causes a tea-colored appearance.)

16. Client is being discharged. While talking with the nurse, she asks if she can return to school. What advice should the nurse give?

You may return when your symptoms subside and you feel able to tackle the rigors of school. (Once client feels able to return to school, she may do so. She should be instructed to follow good handwashing techniques.)