Liver EAQ

Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication?

Reduces the blood ammonia level Rationale: Reducing the blood ammonia level decreases the effect of bacterial activity on blood and wastes in the gastrointestinal tract. Although neomycin is an aminoglycoside antimicrobial, it is not administered to prevent infection. Neomycin has little or no effect on intestinal edema. Neomycin does not reduce abdominal distention.

A client with Laënnec cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority?

Implement fall precautions/prevention measures Rationale: Measures must be taken immediately to ensure client safety. Sedatives are contraindicated because they mask the progressive signs of hepatic encephalopathy. Although the healthcare provider should be notified, the nurse should first take measures to ensure client safety. High serum ammonia levels, not hypoxia, cause hepatic encephalopathy.

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. What is the nurse's best reply?

"All family members, including your child, need to wash their hands after using the bathroom."' Rationale: Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper hand washing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. It is not feasible to clean "from top to bottom" each time the bathroom is used. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Hand washing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which client history item?

Black, tarry stools Rationale: The priority is black (tarry) stools that indicate upper gastrointestinal (GI) bleeding; digestive enzymes act on the blood, resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. Nausea is a common symptom of gastritis but is not life threatening. Attempts to control alcoholism should be supported, but this is a long-term goal; assessment of bleeding takes priority. Investigation of bleeding takes priority; later the nurse should help to identify irritating foods that may be increasing the pain after eating and are to be avoided.

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. For which condition is it most important for the nurse to assess this client?

Blood in the stool Rationale: Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis. Although food intolerances should be identified, there is no immediate threat to life. Although increased intraabdominal pressure because of ascites may precipitate nausea, there is no immediate threat to life. Hourly urine output measurements are unnecessary.

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority?

Institute fall prevention/safety measures Rationale: The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority. Although the client may have dyspnea as a result of ascites, it is not life threatening; safety is the priority. Although measuring abdominal girth daily is done to monitor ascites, it is not the priority for a confused client; safety is the priority. Testing stool specimens for blood is not the priority; providing for client safety is the priority.

A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes what statement?

"I should wash my hands frequently." Rationale: Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. The response "Launder my clothes separately" will not deter the spread of the virus; handwashing is necessary. Putting used tissue in the garbage is important, but handwashing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

On the third day of hospitalization, a client with a history of heavy drinking begins experiencing delirium alcohol withdrawal syndrome. What is the most appropriate response by the nurse when the client begins experiencing hallucinations?

Administering the prescribed medication to the client to subdue the agitated behavior Rationale: The nurse must administer the prescribed medication to the client to subdue the agitated behavior in this life-threatening situation. The client's central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects. The client needs intervention because the hallucinations are not dreams. Focusing on the sensations associated with the withdrawal syndrome is not therapeutic; it is not helpful to tell the client that the hallucinations are not real, because they are real to the client. Validation reinforces the client's distorted perceptions of reality, is not helpful, and may be unsafe.

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply.

Ascites Pruritus Jaundice Rationale: Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.

A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply.

Avoiding aspirin and aspirin-containing products Avoiding acetaminophen and products containing acetaminophen Avoiding coughing, sneezing, and straining to have a bowel movement Rationale: Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high-carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.

A nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos should the nurse include in the teaching plan?

Hepatitis C Rationale: Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or water.

A client with a history of cirrhosis of the liver develops heart failure. When ventricular bigeminy develops, the provider orders lidocaine. What alterations in lidocaine dosages does the nurse anticipate?

Lower because the drug is metabolized at a diminished rate Rationale: The client has heart failure, which causes liver congestion, further compromising liver function; therefore, less than the usual adult dose will be prescribed because the liver will not be able to break down lidocaine as effectively as necessary. A dose higher to compensate for the impaired liver function increases the concentration of lidocaine in the blood, leading to toxicity. Lidocaine is metabolized by the liver; other organs cannot assist in the process. This may be life threatening because the client cannot metabolize lidocaine at the required rate, and toxicity may result.

A client who experiences anorexia and fatigue develops jaundice. A diagnosis of hepatitis A is made. The client's spouse and adult children who still live at home ask whether they should receive gamma globulin. Which is the most appropriate response by the nurse?

"You should call your primary health care provider immediately about getting gamma globulin." Rationale: Gamma globulin provides passive immunity to hepatitis type A if given to household or sexual contacts within 2 weeks of exposure. Gamma globulin may provide some protection; contact, not droplet, precautions should be followed. Gamma globulin provides passive immunity for hepatitis type A, not type B. Gamma globulin provides some protection; the hepatitis type A virus is found in the stools of infected individuals before the onset of symptoms and during the first few days of illness.

A client with ascites is scheduled to have a paracentesis. What should the nurse include in the plan of care?

Instruct the client to urinate before the procedure. Rationale: The bladder should be empty to prevent injury during insertion of the trocar. Shaving the hair from the needle insertion site is not necessary. Positioning a client on the side with the hips and knees flexed generally is the position assumed by the client for a spinal tap, not paracentesis; the upright position is assumed for a paracentesis to allow accumulation of fluid in the lower abdomen by gravity. Although regular monitoring of girth is important, it is not necessary immediately before this procedure; abdominal girth is measured at the level of the umbilicus.

A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission?

Monitor vital signs Rationale: The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Increasing fluid intake is contraindicated initially because it may cause cerebral edema and the client has ascites. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.

A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance?

Reduction of colloidal osmotic pressure in the blood Rationale: Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.

In addition to hydration during alcohol withdrawal delirium, parenteral administration of lorazepam is prescribed for a client. The nurse knows that this drug is given during detoxification primarily for what purpose?

To reduce the anxiety tremor state and prevent more serious withdrawal symptoms Rationale: Lorazepam potentiates the actions of gamma-aminobutyric acid, which reduces the anxiety and irritability associated with withdrawal. This drug helps reduce the risk of seizures but does not prevent physical injury if a seizure occurs. Although the drug may enable the client to sleep better during periods of agitation, this is not the primary objective of using the drug. The ability of the client to accept treatment depends on readiness to accept the reality of the problem.

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom?

Clay-colored stools Rationale: Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.

The primary health care provider prescribes contact precautions for a client with hepatitis A. What nursing interventions are required for contact precautions?

Gown and gloves when handling articles contaminated by urine or feces Rationale: Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.

A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take?

Use gloves when removing the client's bedpan. Rationale: The virus is present in the stool of clients with hepatitis A; therefore, standard precautions should be followed when handling excretions. The virus also may be present in urine and nasotracheal secretions. The Centers for Disease Control and Prevention (CDC) (Canada: Public Health Agency of Canada (PHAC)) indicate that only standard precautions are necessary when caring for a client who is positive for the presence of hepatitis A; if a client is incontinent or using an incontinence device, the CDC (Canada: PHAC) recommends that contact precautions be implemented. Bringing food to a client requires no precautions; however, disposable utensils should be used and utensils discarded following standard precautions because the client's nasotracheal secretions contain the virus. Hepatitis A usually is not transmitted via the air.