Liver part 2
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for thisclient? 1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet
1Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction ofhepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to theliver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepaticencephalopathy, a low-protein diet would be prescribed.Test-Taking Strategy: Focus on the subject, an elevated ammonia level. Recall the physiology of the liver to assist in answering.Also, note that the correct option and option 2 are opposite, which should provide you with the clue that one of these options is correct.Review: Dietary measures for the client with a high ammonia levelLevel of Cognitive Ability: UnderstandingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process—PlanningContent Area: Adult Health—GastrointestinalPriority Concepts: Clinical Judgment; InflammationReference: Lewis et al (2011), p. 1080.
A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply. A) Ammonia conversion B) Glucose metabolism C) Carbohydrate metabolism D) Protein metabolism E) Zinc storage
A) Ammonia conversion B) Glucose metabolism D) Protein metabolism Functions of the liver include the metabolism of glucose, protein, fat, and drugs; conversion of ammonia; storage of vitamins and iron; formation of bile; and excretion of bilirubin. The liver is not responsible for the metabolism of carbohydrates or the storage of zinc.
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? A) Black and tarry B) Clay-colored or whitish C) Yellow-green D) Blood tinged
B) Clay-colored or whitish 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.
While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as:* A. Metallic Hepatico B. Fetor Hepaticus C. Hepaticoacidosis D. Asterixis
B. Fetor Hepaticus
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.
3Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with thepalms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy isdeveloping. Options 1, 2, and 4 are incorrect.Test-Taking Strategy: Focus on the subject, the procedure for assessment of asterixis. Remember that asterixis is irregular flappingmovements of the fingers and wrists. This will direct you to the correct option.Review: AsterixisLevel of Cognitive Ability: ApplyingClient Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process—AssessmentContent Area: Adult Health—GastrointestinalPriority Concepts: Clinical Judgment; InflammationReference: Lewis et al (2011), p. 1077.
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? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Ataxia
A) Asterixis Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13).
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. A) Enlarged liver size B) Excess storage of vitamin C C) Hemorrhoids D) Accelerated behaviors and mental processes E) Ascites
A) Enlarged liver size C) Hemorrhoids E) Ascites Early in the course of cirrhosis, the liver tends to be large, and the cells are loaded with fat. The liver is firm and has a sharp edge that is noticeable on palpation. Portal obstruction and ascites, late manifestations of cirrhosis, are caused partly by chronic failure of liver function and partly by obstruction of the portal circulation. The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and shunting of blood from the portal vessels into blood vessels with lower pressures. These distended blood vessels form varices or hemorrhoids, depending on their location. Because of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, and K), signs of deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Additional clinical manifestations include deterioration of mental and cognitive function with impending hepatic encephalopathy and hepatic coma, as previously described.
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) Respiratory assessment related to increased thoracic pressure B) Peripheral vascular assessment related to immobility C) Skin assessment related to increase in bile salts D) Urinary output related to increased sodium retention
A) Respiratory assessment related to increased thoracic pressure 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.
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) Folic acid deficiency C) Vitamin A deficiency D) Riboflavin deficiency
A) Vitamin K deficiency 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 is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient?* A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts
A. Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can't happen). Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.
A patient with Hepatitis is extremely confused. The patient is diagnosed with Hepatic Encephalopathy. What lab result would correlate with this mental status change? A. Ammonia 100 mcg/dL B. Bilirubin 7 mg/dL C. ALT 56 U/L D. AST 10 U/L
A. When ammonia levels become high (normal 15-45 mcg/dL) it affects brain function. Therefore, the nurse would see mental status changes in a patient with this ammonia level.
The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? Select all that apply:* A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis
B and D. A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands) etc. This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status (NOT stuporous), decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level.
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
B) Transjugular intrahepatic portosystemic shunting (TIPS) 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.
When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? A) Weight loss of 2 pounds in 3 days B) Anorexia for more than 3 days C) Change in the client's handwriting and/or cognitive performance D) Constipation for more than 2 days
C) Change in the client's handwriting and/or cognitive performance The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.
During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings?* A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level
C. Based on the assessment findings and the fact the patient has cirrhosis, the patient is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings.
The physician writes an order for the administration of Lactulose. What lab result indicates this medication was successful? A. Bilirubin <1 mg/dL B. ALT 8 U/L C. Ammonia 16 mcg/dL D. AST 10 U/L
C. Lactulose is ordered to decrease a high ammonia level. It will cause excretion of ammonia via the stool. A normal ammonia level would indicate the medication was successful (normal ammonia level 15-45 mcg/dL).
A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? A) Portal hypertension B) Asterixis C) Cirrhosis D) Hepatic encephalopathy
D) Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces 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.
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? A) Kanamycin B) Spironolactone C) Cholestyramine D) Lactulose
D) Lactulose Lactulose 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 are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
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) Serum potassium level of 3.5 mEq/L B) Serum sodium level of 135 mEq/L C) Blood pH of 7.25 D) Loss of 2.2 lb (1 kg) in 24 hours
D) Loss of 2.2 lb (1 kg) in 24 hours 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 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? A) Relieving the client's anxiety B) Controlling bleeding C) Maintaining fluid volume D) Maintaining the airway
D) Maintaining the airway 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 can be 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.
What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? A) Raise all four side rails on the bed B) Apply soft wrist restraints C) Prevent visitors, so as not to agitate the client D) Pad the side rails on the bed
D) Pad the side rails on the bed Padding the side rails can reduce injury if the client becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint, and this would not be an initial measure to implement. Family and friends generally assist in calming a client.
Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency? A) Hypoprothrombinemia B) Night blindness C) Beriberi D) Scurvy
D) Scurvy Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.
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) Acetazolamide (Diamox) B) Furosemide (Lasix) C) Bumetanide (Bumex) D) Spironolactone (Aldactone)
D) Spironolactone (Aldactone) 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.
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 is avoiding the nurse. B) The client is relaxed and not in pain. C) The client didn't take his morning dose of lactulose (Cephulac). D) The client's hepatic function is decreasing.
D) The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. 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 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: A) elevated liver enzymes and low serum protein level. B) subnormal clotting factors and platelet count. C) elevated blood urea nitrogen and creatinine levels and hyperglycemia. D) subnormal serum glucose and elevated serum ammonia levels.
D) subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.
